
Class - 
Book. 



COPYRIGHT DEPOSIT 



DISEASES OF 

THE ANUS, RECTUM, 

AND SIGMOID 



FOR THE USE OF 

STUDENTS AND GENERAL PRACTITIONERS 



BY 

SAMUEL T. EARLE, M.D. 

PROFESSOR EMERITUS OF DISEASES OF THE RECTUM IN THE BALTIMORE MEDICAL COLLEGE 

SURGEON IN CHARGE OF RECTAL DISEASES AT ST. JOSEPH'S HOSPITAL, THE 

HEBREW HOSPITAL, AND THE HOSPITAL FOR WOMEN 



WITH 152 ILLUSTRATIONS IN THE TEXT 




PHILADELPHIA & LONDON 

J. B. LIPPINCOTT COMPANY 






Copyright, 191 1, by J. B. Lippincott Company 



CCU280295 



This Book 
is Gratefully Dedicated to 

WILLIAM T. COUNCILMAN, M.D. 

IN APPRECIATION OF THE MANY ADVANTAGES AFFORDED ME 

BY HIM DURING MY POSTGRADUATE COURSE AT 

THE JOHNS HOPKINS HOSPITAL 



PREFACE 

It is now many months since I set out upon the task of 
gathering into one volume all the information concerning dis- 
eases of the rectum and anus, derived from my own experience 
and that of others, which would be helpful to both students 
and the general practitioner. The latter, owing to the nature 
of the symptoms and the inaccessibility of a specialist, has 
often the entire treatment in his hands and has to face a situa- 
tion in which a complete pathological knowledge of the con- 
ditions is absolutely essential. 

The maladies discussed are very common but very stub- 
born and particularly annoying and painful. My chief care 
has been to include the most recent and effective methods of 
cure and to give these comprehensively and succinctly, know- 
ing a busy doctor will not search for therapeutic or operative 
technic hidden in verbose phrasing. Nor do I quote many 
cases only slightly dissimilar, but rather those of rare finding or 
needed for the elucidation of methods advised. 

The pictures, numbering one hundred and fifty-two, most of 
them specially drawn, are fitly wedded to the text when such 
union engenders a fuller appreciation of facts stated. The 
labor of my artist, Walter R. Gale, and the promptness and 
intelligence with which he has availed himself of every 
proffered opportunity to witness operations and dissections 
deserves as much attention from my readers as praise from 
myself. 

In the chapter on Constipation I have striven to write in 
a form most convenient for reference, and to cover the whole 
etiological field. In another part of the book are descriptions 
of certain forms of ulceration not found in any text-book that 
I know of, such as Infection by Bilharzia Haematobia, Actino- 
mycosis, and Spontaneous Gangrene of the Rectum. Con- 



PREFACE 

genital Idiopathic Dilatation of the Colon (Hirschsprung's 
Disease) is also described at length. 

Great assistance has been given by my colleague, Dr. 
Arthur Hebb, who made all the dissections necessary for the 
original anatomical plates and some of the outline drawings, 
looked up references, and helped me in so many ways that my 
most appreciative thanks are due to him. To the members of 
the Proctologic Society and to my confreres, who have all 
so courteously and promptly responded to every request, I 
tender my very cordial thanks. 

My thanks are due to Miss Davina Waterson not only for 
her corrections of the manuscript but also for her kind criti- 
cism of the contents, and they are also due to the J. B. Lippin- 
cott Company, who have done all in their power to procure 
the best possible results. 

S. T. E. 



CONTENTS 

CHAPTER I. 

Anatomy, and Physiology. 

Anatomy — Development — Pelvic Triangles — Ischiorectal Fossae — 
Muscles of the Perinseal — Muscles of the Anorectal Region — Nerve 
Supply — Lymphatics — The Rectum — Mucous Membrane — Sub- 
mucous Layer — Muscular Wall — Columns of Morgagni — Hous- 
ton's Valves — Arteries — Relation of Rectum — Sigmoid Flexure 
— Elood Supply — Nerve Supply — Physiology — Defecation 1-26 

CHAPTER II. 

Examination. 

History — Position — Digital Examination — Instrumental Examina- 
tion — Proctoscope — Sigmoidoscope — Limit of Ocular Examina- 
tion — Examination of Faeces — General Anaesthesia — Local Anaes- 
thesia — Spinal Anaesthesia 27—56 

CHAPTER III. 

Constipation. 

Illoway's Classification — Consequences of Constipation — Treatment 
— Massage — Hydrotherapy — -Electricity— Therapeutic — Opera- 
tive Treatment — Psychotherapy — Method of Treatment 57-9 1 

CHAPTER IV. 

Simple Catarrhal Proctitis; Sigmoiditis; Membranous 
Colitis. 

Acute Catarrhal Proctitis — Chronic Proctitis — Atrophic Catarrh — 

Sigmoiditis — Acute Diverticulitis — Membranous Colitis. .... 92-112 

CHAPTER V. 

Ulcerations, Simple and Specific 

Simple Perineal Ulcerations — Ulceration of the Anal Canal — Ulcera- 
tion of the Rectum and Sigmoid — Follicular Ulceration — Speci- 
fic Ulceration — Tubercular Ulceration — -Acute Tubercular Proc- 
titis — Dysenteric Ulceration — Valvular Caecostomy — Appendi- 
costomy — Ulceration due to Mixed Infection — Venereal Ulcera- 
tion — Diphtheritic Ulceration — Ulceration due to Bilharzia Hae- 

matobia — Actinomycosis — Gangrene of the Rectum 1 13-150 

vii 



viii CONTENTS 

CHAPTER VI. 

Perianal and Perirectal Abscesses. 

Follicular Abscesses — Subtegumentary Abscesses — Ischiorectal Ab- 
scesses — Deep Abscesses — Retrorectal Abscess — Superior Pelvi- 
rectal Abscess — Idiopathic Gangrenous Periproctitis — Interstitial 
Abscesses 1 51-162 

CHAPTER VII. 

Fissure in Ano, or Painful Ulcer. 

Pathology — Etiology — Symptoms — Operative Treatment — Excision 

of Fissure — Complications of Fissure 1 63-1 71 

CHAPTER VIII. 

Malformations of the Anus and Rectum. 

Malformations of the Anus — Malformations of the Rectum — Treat- 
ment — Means for Locating Rectum — The Operation — Colos- 
tomy 172-191 

CHAPTER IX. 

Anorectal Fistula. 

Complete Fistula — Incomplete Fistula — -Constitutional Causes and 
Complications — Tuberculosis — Syphilis — Blind External Fis- 
tula — Blind Internal Fistula — Complete Fistula — Pathology — 
Prognosis — Treatment — Non-operative Treatment — Operative 
— Excision of Fistula — Excision with Immediate Suture — Com- 
plex Fistula — Complications Attending and Following Operation 
for Fistula — Treatment for Incontinence — Protracted Suppura- 
tion Following Operation for Fistula — Complicated Fistula — 
Fistulae that Originate in Diseased Bone — Fistula Originating in 
Other Organs — Operation — Complete Excision of the Fistulous 
Tract Combined with Perineorrhaphy 192-239 

CHAPTER X. 

Hemorrhoids. 

Pathology — Etiology — Complications — Predisposing Causes — Excit- 
ing Causes — External Hemorrhoids — Internal Hemorrhoids — 
Mixed Hemorrhoids — Thrombotic — Connective-Tissue — Treat- 
ment of Internal Hemorrhoids — Injection Method — Electrolysis 
— Angiotribe — Operative Treatment — Ligature — Clamp and Cau- 
tery — Complications Following Operation 240-278 



CONTENTS ix 

CHAPTER XI. 
Prolapse of the Rectum. 

Incomplete — Etiology — Symptoms — Treatment — Complete — First 
Degree — Second Degree — -Third Degree — Symptoms — Etiology 
— Pathology — Treatment — Reduction — Operative Treatment — 
Rectopexy — Sigmoidopexy — Excision — Complications of Pro- 
lapse — Rupture of the Hernial Sac 279-307 

CHAPTER XII. 
Stricture of the Rectum. 

Classification — Annular — Tubular — Linear — Congenital Stricture — 
Intramural Stricture— Neoplastic Stricture— Spasmodic Stric- 
ture — Inflammatory Stricture — Location — Simple Inflammatory 
Stricture — Traumatic Stricture — Tubercular Stricture — Syphil- 
itic Stricture — Pathology — Symptoms — Dilatation — Diagnosis 
— Treatment — Preventive Treatment — Palliative Treatment — 
Electrolysis — Gradual Dilatation — Operative Treatment — Colos- 
tomy — Excision — Proctoplasty 308-327 

CHAPTER XIII. 

Pruritus Ani. 

Reflex Causes — Direct Causes — Symptoms — Treatment — Local — 

Operative 328-337 

CHAPTER XIV. 
Colostomy. 

Left Inguinal — Permanent Left Inguinal — Technic — Temporary Co- 
lostomy — Closure of Artificial Anus 338-349 

CHAPTER XV. 

Pathological Growths, or Tumors of the Anus, 
Rectum, and Sigmoid. 

Malignant Tumors — Innocent Tumors— Classification of Tumors — 
Benign Tumors of the Rectum — Polypus — Fibroma — Myxoma — 
Lipoma — Enchrondroma — Lymphoma — Angioma — Papilloma 
— Hard Papilloma — Condyloma Acuminatum — Soft Papilloma — 
Adenoma — Adenoma Proper — Adenomatosis — Adenoma with 
Bilharzia Haematobia — Symptoms — Diagnosis — Malignant Trans- 
formation — Treatment — Colostomy and Caecostomy— Teratoma 
— Dermoids of the Rectum — Postrectal Dermoids — Rectal 
Dermoids — Postanal Dimples — Hypertrophied Anal Papilla — 
Malignant Tumors of the Rectum — Carcinoma and Sarcoma — 



x CONTENTS 

Types — Seat of Disease — Epithelioma — Adenocarcinoma — 
Medullary Carcinoma — Scirrhous Cancer — Colloid Degeneration 
— Symptoms — Manner of Extension — Diagnosis — Treatment — 
Inoperable Cases — Palliative Treatment — Colostomy as a Pallia- 
tive Measure — Operable Cases — Sarcoma — Types of Sarcoma — 
Symptoms — Diagnosis — Treatment — Prognosis 350-400 

CHAPTER XVI. 

Extirpation of the Rectum. 

Perineal Method — Sacral Method — Vaginal Method — Abdominal 

Method — Combined Method — Combined Operation 401-426 

CHAPTER XVII. 

Wounds, Injuries, and Rupture of the Rectum. 

Wounds and Injuries — Rupture of the Rectum — Prognosis — Symp- 
toms — Treatment 42 7-43 1 

CHAPTER XVIII. 

Foreign Bodies in the Rectum and Sigmoid. 

Foreign Bodies — Symptoms — Diagnosis — Complications — Prognosis 

— Treatment — Removal by Cceliotomy — Operation 432-437 

CHAPTER XIX. 

Hysterical or Irritable Rectum; Neuralgia of the Rectum; 
Obscure Diseases of the Rectum. 

Reflex Irritations — Loss of Normal Sensibility — Treatment 438—441 

CHAPTER XX. 

Pathological Lesions of the Coccyx. 

Malformations — Treatment — Fractures and Dislocations of the Coc- 
cyx—Treatment — Sacrococcygeal Tumors and Cysts — Treat- 
ment — Tapping — Partial Resection — Complete Extirpation — 
Coccygodynia — Etiology — Pathology — Symptoms — Diagnosis — 
Palliative Treatment— Surgical Method — Tenotomy — Total Ex- 
cision 442—449 

CHAPTER XXI. 

Congenital Idiopathic Dilatation of the Colon: Hirsch- 
sprung's Disease. 

History — Terms and Synonyms — Classification — Etiology — Cardinal 
Symptoms — Prognosis — Treatment — Pathology — Lateral An- 
astomosis 450-462 



ILLUSTRATIONS 



FIG. PAGE 

i. Divisions of the pelvic outlet 2 

2. Male perineum. (Plate.) 4 

3. Levator ani muscle • • 6 

4. Sympathetic nerve supply to rectum 7 

5. Sacral plexus. (Plate.) 8 

6. Sagittal section of the pelvis 9 

7. Sagittal section of the rectum. 11 

8. Blood supply to rectum, etc. (Plate.) 16 

9. Knee-chest position 28 

10. Mathews and Hanes examining table 31 

11. Lithotomy position 32 

12. W. D. Allison's examining table 34 

13. W. D. Allison's cabinet 34 

14. Earle's single-blade speculuni 35 

15. Murray's speculum 36 

16. Tuttle's pneumatic proctoscope 37 

17. Pennington's bivalve speculum 39 

18. Kelly's graduated conical dilator 39 

19. Dudley Roberts's rubber bag dilators 40 

20. Rectal curette , 42 

21. Alligator forceps • • 43 

22. Silver probe 43 

23. Grooved directors 43 

24. Murray's scrotal holder and shield 44 

25. Murray's holder and shield in position 45 

26. Showing perineal nerve supply 48 

27. Testing resistance of rectal valve 78 

28. Martin's over and under valvotomy scalpels 79 

29. Pennington's clip for cutting rectal valves 79 

30. Pennington's clip applied 80 

31. Lynch's electric angiotribe 81 

2,2. J. G. Clark's lateral anastomosis 83 

22>. Wolbarst's rectal irrigating tube 94 

34. Wolbarst's rectal irrigating tube 95 

35. Tumor of the sigmoid flexure 103 

36. Tubercular ulceration encircling the sigmoid 121 

37. Gibson's method showing catheter in caecum 130 

38. Catheter in caecum, wound closed 131 

39. Gant's caecostomy. (Plate.) 132 

40. Different steps in Gant's caecostomy 133 



xii ILLUSTRATIONS 

FIG. PAGE 

41. Turtle's modification of Weir's appendicostomy 135 

42. Catheter in position, and ligature 136 

43. Gant's appendicostomy. {Plate.) 136 

44. Spirochete pallida from anal condyloma ■ 141 

45. Abscesses around anus and rectum 154 

46. Fissure in ano 164 

47. Entire absence of anus 173 

48. Anal opening at an abnormal point 174 

49. Rectum ending in cul-de-sac; anus opening into vagina 175 

50. Rectum entirely absent 176 

51. Rectum arrested above anus 177 

52. Rectum opening into some other viscus 178 

53. Rectum opens at the glans penis 179 

54. Rectum opens into the vagina 180 

55. Rectum opens into the bladder 181 

56. Rectum descends posteriorly to anal canal 182 

57. Peritoneal cul-de-sac between rectum and anus 183 

58. Cord between blind ends of anus and rectum 184 

59. Rectum opens into vagina ; anus into blind pouch 189 

60. Showing Fig. 59 after operation 189 

61. Complete and incomplete fistula 192 

62. Tubercular fistula with fibrous infiltration 201 

63. Showing Fig. 62 with wound sutured 202 

64. Shoulder and knee strap applied 205 

65. Earle's hawk-bill knife 207 

66. First step in excision of fistula 209 

67. Fistula threaded on a probe 210 

68. Suturing after excision of fistula 211 

69. Final step in closing fistula 212 

70. Complex fistula 214 

71. Incision for removing scar tissue 219 

72. Chetwood's operation for fecal incontinence 221 

73. Chetwood's operation, second step 222 

74. Rectovaginal and vesicovaginal fistula 233 

75. Lauenstein's operation for fistula 236 

76. Closure of rectovaginal fistula 238 

77. Mixed hemorrhoids 245 

78. Thrombotic hemorrhoid 246 

79. Pile ointment pipe 251 

80. Collapsible metallic tube 251 

81. Collier F. Martin's conical speculum 252 

82. Diagrammatic sketch of injection points 254 

83. Small electrothermic angiotribe 258 

84. Shield for use with angiotribe 258 

85. Transfixing hemorrhoid with needle 260 

86. Turtle's hemorrhoidal forceps 262 

87. Linthicum's hemorrhoidal clamp 263 



ILLUSTRATIONS xiii 

FIG. PAGE 

SS. Murray's hemorrhoidal clamp 264 

89. Earle's straight hemorrhoidal forceps 269 

90. Hebb's modification of Fig. 89. 270 

91. Earle's modification of Whitehead's operation 271 

92. Second step of Fig. 91 . 272 

93. Hebb's curved scissors 273 

94. Fig. 91 completed 274 

95. Modification of Earle's operation 276 

96. Fig. 95 completed 277 

97. Incomplete prolapse 279 

98. Complete prolapse of rectum 283 

99. Complete prolapse of rectum, third degree 284 

100. Rectopexy for procidentia recti 292 

101. Rectopexy — the gut brought through the incision 293 

102. Rectopexy — the sutures through the tissues 294 

103. Rectopexy — the operation completed 295 

104. Sigmoidopexy — showing method of operation 297 

105. Sigmoidopexy — incision }i inch from anal margin 300 

106. Sigmoidopexy — clamp applied to gut 301 

107. Sigmoidopexy — gut being sutured 302 

108. Prolapse of uterus, vagina, and rectum 304 

109. Fig. 108 with multiple adenoma 305 

no. Olive-shaped, hard-rubber dilators 320 

in. Cracked skin in pruritus ani 331 

112. Elliptical incisions about anal margin 334 

113. Flap dissected back, showing nerve filaments 334 

114. Krouse's radial incisions 336 

115. Inguinal colostomy, first step 341 

116. Inguinal colostomy, second step 343 

117. Inguinal colostomy, third step 344 

118. Inguinal colostomy, completed 345 

119. Compress and receiver, inguinal colostomy 346 

120. Paul's intestinal tubes 347 

121. Polypus from large hemorrhoid 356 

122. Nevus simplex 361 

123. Condyloma acuminatum 364 

124. Inflammatory fibrous papilloma 365 

125. Finger-like papillomatous outgrowths 365 

126. Rectal adenoma 367 

127. Multiple adenoma 368 

128. Adenocarcinoma, alcohol specimen 375 

129. Adenocarcinomatous ulcer. {Colored Plate.) 376 

130. Colloid adenocarcinoma of the rectum 376 

131. Photomicrograph of Fig. 130 2>77 

132. Epithelioma of the anal margin 380 

133. Adenocarcinoma 382 

134. Perineal extirpation of rectum 405 



xiv ILLUSTRATIONS 

FIG. PAGE 

135. Perineal extirpation — loosening rectum 406 

136. Perineal extirpation — the pouch laid open 407 

137. Perineal extirpation, completed 408 

138. Extirpation of rectum by sacral route, first step 410 

139. Rectum, with principal vessels. (Plate.) 410 

140. Second step in bone-flap operation 411 

141. Third step in bone-flap operation 412 

142. Fifth step in bone-flap operation 413 

143. Sacral anus 414 

144. Incision in vaginal extirpation 418 

145. Separation of rectum from vaginal walls 419 

146. Colorectostomy (invagination of colon) 420 

147. Extirpation of the rectum 425 

148. Gant's scissors for excising coccyx 448 

149. Excision of the coccyx 448 

150. Megacolon (Hirschsprung's disease) 453 

151. Lateral anastomosis, ileum and sigmoid 459 

152. Redundant sigmoid in four-year-old boy 460 



DISEASES OF THE ANUS, 
RECTUM, AND SIGMOID 

CHAPTER I 

ANATOMY AND PHYSIOLOGY 

Before undertaking a study of the diseases of the anus, 
rectum, and colon it is necessary that their anatomy and 
physiology should be studied, or it will be impossible to under- 
stand their relation, interdependence, or treatment. 

ANATOMY 

Development. — The sigmoid and rectum are developed 
from the hypoblast and mesoblast of the ovum; the anus is 
developed from the epiblast. From the hypoblast the mucous 
membrane and probably the submucous tissue develop, while 
the inner layer of the mesoblast forms the muscular, peritoneal, 
and glandular portions of the bowel (Shaffer). 

Up to the sixth week of gestation the large and small intes- 
tines are one cavity of nearly uniform calibre, with the excep- 
tion of the lower portion of the hind-bowel. After the sixth 
week the colon and rectum grow more rapidly than the small 
intestine, and extend downward, approaching nearer the outer 
layer of the mesoblast and epiblast. 

While this development of the rectum is going on an 
invagination of the epiblast takes place which is called the 
proctodeum. This invagination increases until the outer and 
inner layers of the mesoblast are pressed together and absorbed 
and the epiblast of the proctodeum and hypoblast of the hind- 
gut approach each other and form a double septum between 

1 



2 DISEASES OF ANUS, RECTUM, AND SIGMOID 

the rectum and the anus; finally this septum is absorbed and 
the continuity of the rectum with the anal canal is complete. 
The location of the septum, however, is marked by a narrow 
zone, whose superficial tissue is neither mucous nor cutaneous 
but a transitional form — mucocutaneous — which has been 
termed by Stroud the " pecten." The conjunction takes place 
generally at a point slightly in front of the posterior end of 
the gut, thus leaving a cul-de-sac which is connected with the 
neurenteric canal. This cul-de-sac, although largely absorbed 
during fetal life, becomes the coccygeal gland of Luschka. 




Pig. i. — Divisions of the pelvic outlet — R.A., right anterior quadrant; L.A., left 
anterior quadrant; R.P., right posterior quadrant; L.P., left posterior quadrant; R.A. 
and L.A., uro-genital triangle; R.P. and L.P., rectal triangle. 

Sometimes, through imperfect absorption, there may be a 
congenital posterior rectocele. It is from remains of this cul- 
de-sac that dermoid cysts frequently develop in the rectococcy- 
geal space. 

Pelvic Triangles. — The outlet of the bony pelvis forms an 
imperfect double triangle, which may be divided by an imag- 
inary line running from the anterior border of one tuberosity 
of the ischium to that of the other into an anterior and a pos- 
terior triangle. The anterior one is known as the urogenital 
triangle and the posterior as the rectal triangle (Fig. i). The 
rectal triangle may be further subdivided by a line running 



ANATOMY AND PHYSIOLOGY 3 

from the symphysis pubis to the tip of the coccyx into the 
right and left anterior and posterior quadrants. 

The urogenital triangle contains the genito-urinary organs. 
The rectal triangle contains the anus, rectum, and contiguous 
tissues. The relations of the parts filling in these two triangles 
must be thoroughly understood in order properly to appreciate 
and treat diseases of the rectum. 

Fasciae. — The urogenital triangle is closed in by the peri- 
neum, which is bounded by the anus behind, the scrotum in 
front, and the ischiopubic rami and the ischial tuberosities upon 
the sides ; it is covered superficially by skin, the centre of which 
forms the raphe. Beneath the skin lies the superficial fascia, 
which is subdivided into a superficial and a deep layer. The 
deep layer is firm and close, and is attached at the sides to the 
entire lower border of the ischiopubic rami and the ischio 
tuberosities. Its posterior margin is united to the triangular 
ligament, that of the anterior margin, which is more especially 
associated with the genito-urinary organs, between which 
structure and the deep layer of fascia are the transversus 
perinae muscles. The superficial layer lies directly under the 
skin and is loose and areolar, its spaces being occupied with 
fat-cells. 

The deep fascia of the perineum forms a triangle with its 
apex forward. It extends nearly horizontally sidewise between 
the lateral walls of the pelvis, and ventrodorsally from the 
pubic symphysis to the central point of the perineum, which 
is about an inch in front of the anus. At the base of the 
triangle the fascia is single, but immediately splits into two 
layers, the superficial and the deep, between which are situated 
a part of the urethra with certain of its appurtenances, vessels, 
and nerves. This is known as the triangular ligament of the 
urethra. 

Fossae. — The ischiorectal fossae are the spaces posterior to 
the perineal spaces and separated from them by the wedge- 
shaped border of the perineal fascia and the transversus perinaei 
muscle. They are bounded by the levator ani muscle above, 



4 DISEASES OF ANUS, RECTUM, AND SIGMOID 

the obturator fascia, the obturator interims muscle, the ischium, 
and the sacro-ischiatic ligaments externally, the sacro-ischiatic 
and coccyx posteriorly, and the skin and superficial fasciae 
below. The ischiorectal spaces practically surround the pos- 
terior portions of the anus and rectum, are filled with fat and 
cellular tissue, and are connected by a zone of cellular tissue 
between the fibres of the levator ani muscle and the anococcy- 
geal ligament. It is through this cellular tissue that pus finds 
its way from one fossa to the other. It is in these spaces that 
the blood-vessels and nerves to the anal canal and the sur- 
rounding tissues ramify, none of which, however, are of vital 
importance from a surgical standpoint. 

Muscles of the Perinaei and of the Anorectal Region. — The 
transversus perinaei muscle crosses the posterior border of the 
perineum from one tuberosity of the ischium to the other, and 
nearly corresponds to the imaginary line directed to be drawn 
in dividing the bony outlet of the pelvis ; the accelerator urinae 
muscle runs through the centre of the space, being covered 
by the superficial fascia, and these, together with the external 
sphincter and the sphincter vaginae in women, unite just in 
front of the anus to form the common fibrous centre known as 
the perineal body. 

The muscles that are of especial interest in the anatomy of 
the anorectal region are the corrugator cutis ani, the external 
and internal sphincters, the levator ani, the coccygeus and the 
rectococcygeus. 

Corrugator Cutis Ani (Fig. 2). — This muscle consists 
of a thin layer of striated muscular fibres in the deeper layers 
of the skin surrounding the anus, which in contracting gathers 
the skin into folds. 

External Sphincter (Fig. 2). — This muscle is com- 
posed of striated muscular fibres, which, however, have many 
properties resembling those of plain muscle, to be shown when 
the rectum is physiologically considered later on. It arises 
from the posterior surface of the coccyx and the fibrous layer 
of the skin over this region; passes forward to the posterior 



White Line 

T 



Coiles Fascia 

Obturator Fiscia 

Perineal Shelf 
junction ofCo/lesFascia ' 
and base of "" 
Ligament -r 



Superficial Perineal A. 
LevaYor Am M. 
/>cce/erator_L/rmaeM. j Tuberosity of Ischium 

I Transv?rkusPerinaeiM. T 

Erector Penis, c t, 1 

open, exposing , 1. to Corpus CavernoSL m 
~ r ~A\t^\y £o theduib 

'es Fascia 




Cut end of In fen 

Hemorrhoidal A . Corrugator Cotes Ani M. 
Obturator I 

Fig. 2. — Male perinaeum. 



Inferior Hemorrhoidal A . 

_j_ G/uteusTtiaximus 

Obturator Fascia laid open exposmd\_ **• reflected. 

AlcocK* can*,. J c/3c/c/ f 



ANATOMY AND PHYSIOLOGY 5 

commissure of the anus, where its fibres divide to surround 
this aperture and reunites at the anterior commissure pass 
forward to be inserted into the perineal body. In women, 
some of its fibres are continuous in front with the fibres of 
the sphincter vagina. It is about three inches in length and 
half an inch in width. It is composed of a superficial and a 
deep layer. The fibres of the superficial layer are circular, and 
entirely surround the anus (Fig. 2) ; the fibres of the deeper 
layer are parallel, and lie on each side of the anal canal to' the 
height of about three-quarters of an inch. 

Internal Sphincter. — This muscle is composed of an 
aggregation of the involuntary circular muscular fibres of the 
bowel ; it lies immediately above the external sphincter, from 
which it is separated by a narrow zone of connective tissue, 
and surrounds the upper portion of the anal canal. It is about 
one inch in width but is so variable in thickness that it cannot 
be accurately measured. The line of separation between the 
two sphincters is only perceptible to the touch. 

A third sphincter which was formerly thought to exist is 
now conceded to be an aggregation of the circular muscular 
fibres found at the base of Houston's valves, also that these 
fibres extend into the layers of the valves. 

Levator Ani (Figs. 2 and 3). — This is a broad sheet of 
muscular fibres which form the floor of the pelvis. It arises 
from the inner surface of the symphysis pubis, laterally from 
the pelvic fascia, where it becomes attached to the obturator 
fascia and posteriorly from the spine of the ischium on each 
side. Its anterior fibres pass downward and backward to> the 
central part of the perineum, embracing the prostate ; those at 
the rear pass downward and mesially to the coccyx, and the 
middle fibres, which constitute the bulk of the muscle, run 
downward and inward toward the middle line. Some are 
inserted in the wall of the anal canal and some into the median 
raphe in front of and behind the anal canal. The muscle as a 
whole is in the shape of a cone or shield, with its convex sur- 



6 DISEASES OF ANUS, RECTUM, AND SIGMOID 

face downward. The upper surface is covered with the recto- 
vesical fascia. The two muscles, like all the perineal muscles, 
act in concert. Their contraction lifts the pelvic floor, and 
tends to counteract the action of the sphincters. 

Coccygeus Muscle (Figs. 2 and 3). — This pair of 
muscles complete the muscular floor of the pelvis on each side 
so largely formed by the levator ani. They arise from the 




-Levator ani muscle. 



spine of the ischium, expand into a triangle, and are inserted 
into the margin of the coccyx and the last segment of the 
sacrum. They act with the levator and pull the coccyx for- 
ward when it has been displaced backward, as in defecation 
( Gerrish ) . 

Rectococcygeus Muscle. — These are two flat bands of 
unstriped muscular fibres which have been described by Kohl- 
rausch and Treitz as arising from the coccygeal ligament near 
the tip of the coccyx, passing forward and downward, and 



ANATOMY AND PHYSIOLOGY 



finally blending with the longitudinal muscular fibres of the 
rectum and the pelvic fascia around the anus (Tuttle). 

Nerve Supply of Anus and Rectum. — This comes from 
both sympathetic and cerebrospinal systems. 

The Sympathetic Nerve Supply. — While in man the 
vertebral or stellate ganglia exist only as low as the first and 
sometimes the second lumbar nerves, there are yet visceral 
branches given off from the second, third, and fourth sacral 




Fig. 4. — Sympathetic nerve supply to the rectum. 

nerves to form a part of the nervi erigentes, which may be 
classed in the same category as autonomic nerves (Langley). 
These fibres pass directly to one of the prevertebral plexuses, 
chiefly the inferior hypogastric, or pelvic plexus, the latter of 
which is a thick network of fibres, rich in ganglia, which lies 
on either side of the rectum and is made up of a continuation 
of the hypogastric plexus, offsets from the upper sacral gan- 
glia, and branches from the second, third, and fourth sacral 
nerves. From this plexus autonomic fibres are distributed to 
the rectum and internal sphincter (Fig. 4). 

Cerebrospinal Nerve Supply (Fig. 5). — The cerebro- 
spinal nerve supply to the lower portion of the rectum and 



8 DISEASES OF ANUS, RECTUM, AND SIGMOID 

anus comes almost entirely from the pudic nerve, which is 
made up of branches principally from the third, but also in 
part from the second and fourth, sacral nerves. The branches 
of the pudic nerve that supply the anus, surrounding muscles, 
and skin, are the inferior hemorrhoidal and the deep division 
of the anterior perineal nerve. The former distributes its 
branches in a fan-like manner to the external sphincter muscle 
and to the skin around the anus ; the latter also to the external 
sphincter, the levator ani, and the transversus perinaei muscles. 
It will thus be seen that the sympathetic nerve supply to the 
rectum and sphincter muscles comes from the lumbar and 
sacral portions of the cord; the cerebrospinal from the sacral 
portion of the cord only (Figs. 4 and 5). 

Lymphatics of Anus and Rectum. — Quenu {Bull, de la 
Societe d'anatomie, Paris, 1893, p. 399) has shown the anus 
and rectum to be supplied with three sets of lymphatics, prac- 
tically corresponding to the arterial supply, namely, the supe- 
rior, middle, and inferior plexuses. These follow the course 
of the vessels, the lymphatic glands lying in close apposition 
with the hemorrhoidal veins. 

The superior hemorrhoidal lymphatic plexus, which 
draws the lymph from the middle and upper portions of the 
rectum, connects with a chain of lymphatics which lie between 
the rectum and the anterior surfaces of the sacrum and coccyx, 
and after extending upward in the cellular tissue between the 
folds of the mesentery is connected with the prevertebral lym- 
phatic system. 

The middle hemorrhoidal lymphatic plexus, which 
originates in the mucous and submucous coats of the anterior 
portion of the rectum, empties into the hypogastric plexus. 

The inferior hemorrhoidal lymphatic plexus, which 
originates in the anal and perineal region, does not follow the 
external hemorrhoidal veins very closely, but ramifies beneath 
the skin, and after passing forward and upward finally unites 
with the inguinal lymphatics. It also anastomoses with lym- 




Fig. 5. — Sacral plexus. 



ANATOMY AND PHYSIOLOGY 9 

phatics of the lower portion of the rectum. Clinical experience 
corroborates the connection that exists between the inferior 
hemorrhoidal lymphatics and the inguinal lymphatics, the 
latter being enlarged from malignant and specific disease of 
the anal margin. 



Rectal folds 



Sacrococcygeal, 
articulation 



Hemorrhoidal veins. 



Levator ani 



External 
sphincter 



Internal sphincter 




.Seminal vesicle 
-Symphysis pubis 



■Urethra 
!ulb of penis 
■Internal sphincter 
.Levator ani 



Veins of mucosa of anal canal £ / 

Fold of mucous membrane External sphincter 

Fig. 6. — Sagittal section of pelvis passing through rectum, anal canal, bladder, and urethra. 
(Piersol's Anatomy.) 



ANAL CANAL 

.The anal canal (Fig. 6) is a channel by which the rectum 
empties its contents externally. It is one inch long and runs 
downward and backward. It is lined with mucous membrane 
at the upper end and skin at the lower, with a mucocutaneous 
surface between the two. Outside of this lining the anal canal 
is surrounded at its lower portion by the external sphincter, 
some fibres of the levator ani, the longitudinal muscular fibres 



10 DISEASES OF ANUS, RECTUM, AND SIGMOID 

of the rectum throughout its extent, and the internal sphincter 
around the upper portion. The lateral walls of the tube are 
in contact, and the lining membrane is disposed in small, longi- 
tudinal folds. The distal aperture is the anus, and around it 
the skin is dark brown and puckered in radiating lines. 
Beneath the mucocutaneous lining of this canal, and separating 
it from the muscular layer, is a thin fibrocellular layer which 
closely unites the two adjoining layers. Its circumference is 
about one and three-sixteenth inches. The walls of the anal 
canal contain few glands and blood-vessels but are richly sup- 
plied with terminal nerves. The canal is covered in its lower 
portion by stratified squamous epithelium which undergoes a 
gradual transformation until it ends in the columnar epithe- 
lium of the mucous membrane at the anorectal line. There 
are slight elevations at this anorectal line above the surface of 
the adjoining mucosa, from five to eight in number, which 
assume the form of papillae at their summits. In a large 
majority of cases they are absent, or, at least, not noticeable, 
but when well developed they produce many reflex disturb- 
ances, which are accounted for by their abundant nerve-supply. 

THE RECTUM 

The rectum (Fig. 6) begins at the upper termination of 
the anal canal at the border of the crypts of Morgagni and 
terminates at a point opposite the front of the third sacral 
vertebra, where the large intestine ceases to be provided with 
a mesentery and where the three longitudinal muscular bands 
of the colon spread out and become equally distributed round 
the bowel. At this point a decided narrowing in the calibre 
of the bowel takes place. Its name, which means " straight," 
is made less absurd by the adoption of these terminal points, 
instead of extending it as formerly up to the sacro-iliac joint. 

The rectum occupies the middle line and forms in its 
descent a double anterior posterior curve, the cavity of which 
is directed forward in the superior portion and backward in 
the inferior, and is divided into two parts. The upper, which 



ANATOMY AND PHYSIOLOGY 11 

is covered with peritoneum, is about three inches long and 
extends from the third sacral vertebra to the tip of the coccyx, 
its course conforming to the curve of these bones, to which 
it is attached posteriorly. The lower part, which is shorter, 
bends forward and terminates in a pouch close to the prostate 
gland in the male and the lower part of the vagina in the 
female. 

The anal opening, instead of being at the end of this pouch 
and in the line of the curve of the rectum, is located in the 



J?ECTO-SlG(^ 

CPENIN& 


lU.wAi. 


O'BEIRNES SPR 


VA!AE X-5 


Bra*/ 


\ 






%0 ^ ' 




2Pm 


>■'' 




pF 


?..,...-■ . iJl 







Fig. 7. — Sagittal section of the rectum; Houston's valves, O'Beirne's sphincter. 

under side, considerably in the rear of its blunt end. This 
pouch in front of the anal opening is known as the rectal 
ampulla. 

The length of the rectum varies from about 3^8 to 5^5 
inches in women, and from 4 to 6 inches in men. The cir- 
cumference varies greatly in different individuals, also at 
different portions of the canal. The average circumference in 
the prostatic portion is from 1/5 to 2 inches; at the widest 
portion of the ampulla it is from 2 2 / 5 to 4 inches, and in the 



12 DISEASES OF ANUS, RECTUM, AND SIGMOID 

upper or narrow portion from 2 to 2 4 / 5 inches. Numerous 
instances have been reported in which these figures have been 
greatly exceeded. 

When the rectum is empty the anterior walls are in close 
apposition to the posterior walls. 

The walls of the rectum are composed from within out of 
four coats, viz., mucous, submucous, muscular, and serous. 

The Mucous Membrane. — The mucous membrane is 
thicker, rather darker in color, more vascular and more mobile 
than that of the colon, being very loosely attached through its 
submucous coat to the muscular wall and frequently being 
thrown into horizontal folds above and longitudinal below, 
the latter constituting the columns of Morgagni, between the 
base of which are found the semilunar valves or the crypts of 
Morgagni. It is studded with tubular and muciparous glands, 
together with many closed follicles. 

Structure of the Mucous Membrane. — It is composed 
of three layers, viz., epithelial, glandular, and muscular. 

The epithelial layer consists of columnar cells throughout 
the rectum proper but changes to stratified cells at the extreme 
lower end. Beneath the epithelial is the glandular layer, in 
which are thickly set the glands of Lieberkiihn ; besides these 
are the goblet or mucus-secreting cells. The intertubular 
tissue is a net-work of long meshes, which are supposed to 
constitute the lymph-paths. There are also found between the 
glands of Lieberkiihn small nodules of lymphoid tissue. 

The muscular layer of the mucous membrane, which is 
known here, as elsewhere, as the muscularis mucosa, is better 
developed in the rectum than in other portions of the colon. 

Submucous Layer. — The submucous layer is a very loose 
net-work of elastic and connective-tissue cells. It is rather 
better developed and more elastic than at any portion of the 
intestinal canal. In it ramify the blood-vessels, nerves, and 
lymphatics. 

Muscular Wall. — The muscular wall is composed of cir- 
cular and longitudinal fibres arranged in separate layers. 



ANATOMY AND PHYSIOLOGY 13 

The circular (inner) layer is distributed irregularly, 
being' aggregated at certain levels and spread out at others. 
This aggregation is especially marked at the lower extremity, 
where it forms the internal sphincter. These muscular fibres 
throughout the rectum are separated by connective-tissue 
fibres, which probably accounts for the rapid development of 
connective-tissue in inflamed conditions of these organs. 

Other aggregations of circular muscular fibres occur at 
different portions of the rectum, especially at the base of 
Houston's valves, between the layers of which they enter ; also, 
as described by O'Beirne : another aggregation of these cir- 
cular fibres is found at the juncture of the sigmoid and rectum. 
It is claimed that the contraction of these fibres causes the 
constriction at this point, a fact easily demonstrated by the 
proctoscope. 

Longitudinal Layer. — The longitudinal muscular layer 
is directly outside the circular layer, and is a continuation of 
the three longitudinal muscular bands of the colon which 
form the beginning of the rectum and are spread out evenly 
over the surface of the rectum, though probably a little thicker 
in front and behind. Some fibres of this layer are inserted 
below into the superior pelvic fascia, covering the levator ani 
muscle; others mingle with those of the levator ani and are 
attached with them to the rectal wall ; the remaining fibres pass 
below the two sphincters and are inserted in the superior fascia 
around the anus. 

Serous Coat. — The serous coat is deflected around the rec- 
tum from behind to the front, beginning about the third sacral 
vertebra. It is reflected externally upon the sides of the pelvis, 
thus forming the lateral supports of the rectum. Anteriorly, 
after dipping down for a short distance, it is reflected upon 
the bladder in males and the uterus in females, thus forming 
Douglas's cul-de-sac, which contains loops of the small intes- 
tine, the sigmoid flexure and sometimes the caecum and ovaries. 
The depth to which the serous coat dips down between the 



14 DISEASES OF ANUS, RECTUM, AND SIGMOID 



rectum, uterus, and bladder varies in individuals and under 
different conditions ; the latter varying with the fulness of the 
bladder and rectum and is nearer the anal margin in women 
than in men. The extreme measurements vary from i^ to 
4j4 inches. 

Columns of Morgagni. — As was previously stated, the 
mucous membrane of the lower portion of the rectum is 
gathered into longitudinal folds by the contraction of the 
sphincters ; these folds are known as the columns of Morgagni 
and also as the pillars of Glisson (Fig. 7). They are, of 
course, obliterated by dilatation of the canal. Between each 
pillar the dentate margin of the upper limit of the anal canal 
is stretched across, forming the semilunar valves, the sides of 
the two pillars; the semilunar valves internally, and the rectal 
wall externally form the anal pockets or crypts of Morgagni 
(Fig. 7)- 

The pillars, varying in number from six to twelve, are 
about half an inch in length ; and gradually lost in the smooth 
rectal wall above. The depth of the crypts of Morgagni vary 
in different individuals; in some scarcely noticeable, in others 
measuring from three to five millimetres. They are also 
invariably absent at the anterior and posterior commissures. 
These pockets when pronounced frequently contain foreign 
substances which may give rise to great annoyance. The 
function of these valves and pockets is practically unknown; 
they, probably, result from the puckering of the rectal wall 
by the contraction of the sphincter muscle. 

Valves of Houston. — As mentioned in speaking of the dis- 
tribution of the circular muscular fibres in the rectum, there 
are aggregations of these fibres at different levels, several of 
which were mentioned as being at the base of and entering 
into Houston's valves. These valves can be seen in the inner 
wall of the distended rectum by inflating the same through a 
proctoscope, or as in Fig. 7. In number they vary from one 
to five; ordinarily there are three: superior, middle, and 



ANATOMY AND PHYSIOLOGY 15 

inferior. The middle valve, which is the most constant, rises 
from the right anterior quadrant of the rectal wall and varies 
in location with the depth of Douglas's cul-de-sac, being 
situated just below it. The inferior valve is located upon the 
left posterior quadrant about one inch above the margin of 
the anus, and the superior valve is in the same quadrant, at 
from 3 3 / 5 to 4 2 / 5 inches above the anal margin. There is 
always a well-developed fold or valve at the junction of the 
rectum with the sigmoid, originally described by O'Beirne, 
who attributed to it the function of maintaining the fecal mass 
in the sigmoid flexure until just before the time of defecation. 
It is situated slightly anteriorly and to the right or left side, 
according to the direction of the flexure of the sigmoid upon 
the rectum, and is more accentuated in those cases in which 
this flexure is acute. The rectal valves, crescentic in shape, 
protruding into the cavity of the rectum, varying in extent 
from one-third to one-half of its diameter, are attached to the 
wall of the bowel for a little more than one-half of its circum- 
ference. As stated by Houston in his original paper (1830), 
they consist of two folds of mucous membrane separated by 
cellular tissue and muscular fibres. Subsequently Martin and 
Pennington demonstrated varying amounts of fibrous tissue, 
Schaeffer and other histologists also agreeing upon this sub- 
jacent layer of fibrous tissue. At its base in the submucosa are 
seen the arteries and veins for its special nutrition, also some 
lymph-nodules and large sympathetic ganglia. According to 
Martin, circular muscular fibres are found at the base of the 
valves. These fibres may in some instances ' extend to the 
middle and even to the free border of the valves. Martin also 
states that sometimes the longitudinal muscle spans the base 
of the valve without deflection. The base of the valves where 
they join the rectal wall is much thicker than the free border 
and convex on their surface. Their attachment to the rectal 
wall is not a horizontal plane, but is effected spirally, being 
slightly higher at the upper than at the lower junction, which 



16 DISEASES OF ANUS, RECTUM, AND SIGMOID 

gives easy exit to the fecal matter, letting it down from a 
higher to a lower plane gradually. 

In their normal condition the valves are usually thin and 
flexible, offering little resistance to the passage of fecal matter. 
A more detailed description of these valves is given in T. C. 
Martin's article (Philadelphia Medical Journal, 1899), and that 
by J. Rawson Pennington (American Medical Journal, Decem- 
ber, 1900). It has not been shown in any examination hitherto 
made that the peritoneum dips into the groove at the base of 
the valve. The function of these valves is to support the fecal 
mass through the rectal canal, and to ease it down gradually. 
Being attached to the wall of the rectum on an incline plane, 
they impart to the fecal mass a rotary motion. 

Arteries. — Those that supply the rectum are the superior, 
middle, inferior hemorrhoidal, and middle sacral. 

The Superior Hemorrhoidal Artery (Fig. 8). — This, 
the terminal division of the inferior mesenteric artery, passes 
down between the folds of the mesorectum, and at the level of 
the second sacral vertebra divides into two, sometimes three, 
divisions ; the left branch being distributed to the left side and 
to the anterior surface of the rectum, the right branch to the 
right side and the posterior surface of the bowel. Penetrating 
the muscular wall of the rectum about 4^/2 inches above the 
anal margin, they subdivide into numerous branches and 
descend in the submucous coat, terminating in the lower limits 
of the rectum. They anastomose with branches from the 
middle hemorrhoidal and middle sacral arteries. 

The Middle Hemorrhoidal Artery. — This gener- 
ally arises from the hypogastric artery, but may arise 
from the internal iliac or the prostatic. It passes through the 
superior pelvirectal space, distributing some branches to the 
anterior surface of the rectum and others to the seminal 
vesicles and prostate in men and to the vagina in women. It 
also supplies the levator ani muscle. 

The inferior hemorrhoidal artery (Fig. 2) arises 
from the internal pudic, crosses the ischiorectal fossa obliquely 



r 



% Colon 



% 




A 



W 



Fig. 8. — The blood supply to the rectum, sigmoid and colon 



ANATOMY AND PHYSIOLOGY 17 

from behind and externally, and supplies the levator ani, the 
two sphincters, the skin, and the superficial fascia around 
the anus. 

The middle sacral artery arising from the posterior 
portion of the aorta just before it divides into the common 
iliacs, supplies the posterior surface of the rectum. Most of 
these arteries anastomose freely with each other. 

Veins. — The veins of the rectum correspond in name and 
direction to the arteries, but the superior hemorrhoidal veins 
return their blood through the inferior mesenteric veins into 
the portal circulation. This forms the venous supply of the 
rectum proper. The middle and external hemorrhoidal veins 
and the middle sacral veins collect the blood from the anus 
and its immediate surroundings and return it to the general 
circulation through the vena cava. The dividing line between 
the circulation of the rectum proper, the anus, and its sur- 
rounding tissues is the anorectal line, but under certain con- 
ditions the blood from the two systems intermingles, through 
anastomosing branches. According to Quenu and Testut 
these anastomosing veins are provided with valves, and this 
interferes with the communication between the two systems, 
except in certain directions. The beginning of the internal 
hemorrhoidal plexus is marked by small venous sacs or pools 
about the size of a grain of wheat. These little pools sur- 
round the rectum just above the anorectal line ; from them 
small veins proceed in all directions, and above the margin of 
the internal sphincter they unite to form large trunks. 

Cellular Spaces Surrounding the Rectum. — Surrounding 
the rectum there are certain cellular spaces which must be 
understood in order to appreciate its relations to adjoining 
organs, and how collections of pus are retained and confined 
to certain localities. That portion of the organ between the 
peritoneal attachment above and the superior surface of the 
levator ani below is surrounded entirely by cellulo fibrous 
tissue, in which the blood-vessels, nerves, and lymphatics 
ramify. It is deeper behind than in front. The outer portion 



18 DISEASES OF ANUS, RECTUM, AND SIGMOID 

of this layer is fibrous and originates in the fascia lining of the 
true pelvis. It is reflected from the pelvis in a double layer 
at the points where the lateral sacral arteries diverge, the 
inner of which attaches itself to the sides of the rectum. 
These folds form the lateral ligaments of this portion of the 
rectum, as described by Jonnesco and Ombredanne and are its 
principal supports at this point. The outer layer of this fascia 
is attached along the border of the sacrum. Between these 
layers posteriorly is a cellulovascular layer, which extends 
from the superior fascia of the levator ani, below, upward 
between the layers of the mesorectum, to connect with the pre- 
vertebral cellular layer of the abdominal cavity. This is 
known as the retrorectal space. 

This fibrocellular space surrounding the rectum is further 
subdivided by the lateral ligaments of the rectum into the 
anterior cellular space, which separates the rectum from the 
prostate and seminal vesicle in men, and from the broad liga- 
ments and uterus in women. This anterior cellular space is 
bounded in front by an aponeurosis which is closely attached 
to the prostate, extends over the seminal vesicles backward, 
and with the lateral ligaments is attached to the sides of the 
rectum. It is also attached to the anterior wall of the rectum, 
thus subdividing this anterior space into two spaces known 
as the superior pelvirectal. In women this aponeurosis is 
attached to the upper surface of the vagina and to the base of 
the bladder. It is in these anterior spaces that abscesses origi- 
nating in the genito-urinary organs often develop and open 
into the rectum high up, or frequently burrow upward and 
forward, opening in the inguinal region. Collections of pus 
in the retrorectal space are not likely to extend into the pelvi- 
rectal space, on account of the intervening lateral ligaments 
of the rectum, which separate the two, but they generally open 
into the rectum or into one of the ischiorectal fossae. 

The Relation of the Rectum. — The relation of the rectum 
with the adjoining organs is as follows : Anteriorly at its 
lower portion with the prostate and membranous urethra in 



ANATOMY AND PHYSIOLOGY 19 

men, and with the posterior vaginal wall in women. Passing 
upward, it is in relation with the urogenital organs, but not so 
closely, a space being left between, known as the perineal body. 
This lower portion of the rectum laterally is in relation with 
the external sphincter ani, the levator ani muscle, and fascia; 
posteriorly with the same muscle and with the cellular tissue 
which separates the rectum and the gland of Luschka from 
the coccyx. The peritoneal portion of the rectum is in relation 
anteriorly with the bladder, prostate, and seminal vesicle in 
men, and with the vagina in women. Posteriorly to and above 
these points is the peritoneal cul-de-sac called prostatovesical 
in men, and Douglas's cul-de-sac in women. This cul-de-sac 
contains a portion of the sigmoid flexure and loops of the 
small intestine, with which the rectum is in relation. 

Below the peritoneum laterally and posteriorly, as stated 
before, the rectum is surrounded by cellular tissue, until the 
muscles below are reached. In this cellular tissue posteriorly 
is to be found the sacral plexus, sympathetic ganglia, and the 
fascial origin of the pyramidal muscles. These relations show 
that the rectum is not so closely related to the pelvic contents 
but that it can be removed, taking proper care, without injury 
to any of the important organs, and shows it to be fixed in its 
normal position. The supports of the organ are the perito- 
neum and its connective-tissue attachments to adjoining organs 
above, below with the external sphincter, levator ani, and 
rectococcygeus muscles, and its fibrous attachments to the 
coccyx, prostate, or vagina. In the middle portion are the 
fibrocellular tissue and the lateral ligaments. 

SIGMOID FLEXURE 

The sigmoid flexure is that part of the large intestine which 
is so tortuous as to suggest its resemblance to the Greek letter 
sigma. It is the most movable portion of the large intestine. 
It is continuous below with the rectum opposite the third 
sacral vertebra at the median line. It begins on the plane of 
the crest of the left ilium, passes down within an inch and a 



20 DISEASES OF ANUS, RECTUM, AND SIGMOID 

half of Poupart's ligament, bends sharply towards the middle 
line, crosses the psoas magnus muscle, dips into the cavity of 
the true pelvis, rises to the brim on the right side, and thence 
curves backward, downward, and inward, to join the rectum. 
It is fourteen or more inches long. For its uppermost three 
inches it has a serous covering on its front and sides only, 
but below this it has a mesocolon for its entire length. Its 
mesocolon is much longer in the middle portions than toward 
the end, and is frequently so abnormally long in its middle as 
to give rise to acute flexures in this portion of the bowel. Its 
diameter is less than the descending colon above, and grad- 
ually diminishes toward its lower end. The three longitudinal 
muscular bands are continued for the greater part of its course, 
but as the end is approached those that are behind spread out 
and join their fellows, so that the rectum begins with a uni- 
form outer muscular layer (Fig. 8). 

The walls of the sigmoid are composed of four layers, the 
mucous, submucous, muscular, and serous. 

The Mucous and Submucous Layers. — The mucous and 
submucous layers differ in no essential from those of the 
rectum, except that the solitary follicles are not so numerous, 
the mucous membrane is not quite so thick, so loosely attached, 
nor so redundant as to allow it to be thrown into folds. 

The Muscular Layer. — The arrangement of its longitudinal 
muscular layer has already been described. The circular fibres 
are distributed much more evenly than around the rectum. 

The Serous Layer. — The part taken by the peritoneal layer 
in the formation of the mesosigmoid has also been described. 
Otherwise it surrounds the sigmoid as it does the small intes- 
tines. Hensing and Roser first pointed out the funnel-shaped 
cul-de-sac formed at the point where the mesosigmoid crosses 
the iliac artery, a little to the left of the median line. Around 
this orifice are situated arteries above and at the sides. It is 
an important guide to the location of these vessels and can be 
seen by turning the sigmoid upward. 



ANATOMY AND PHYSIOLOGY 21 

Blood Supply. — The blood supply of the sigmoid is through 
the sigmoid arteries, which are branches of the inferior mesen- 
teric artery; they anastomose with the colonic arteries above 
and the superior hemorrhoidal arteries below (Fig. 8). 

The veins of the sigmoid follow the same course as the 
arteries and empty into the inferior mesenteric vein. 

The Nerve Supply. — These are principally autonomic 
fibres, with the exception of a few of the sensory type, which 
are derived from the lumbar and sacral plexuses. 

The sigmoid when empty lies almost in the pelvic cavity; 
it is therefore called the pelvic colon. When distended by 
gas or fecal matter it rises into the abdominal cavity. 

PHYSIOLOGY OF THE ANUS, RECTUM, AND SIGMOID 

The function of the anus is to furnish exit for the fecal 
matter, it being provided also with mechanism for controlling 
discharges for a certain time, or, when under the control of 
the will, until convenient. This control is effected both by 
voluntary and involuntary muscles, viz., the external and in- 
ternal sphincters. Usually the anus is closed, except when the 
sphincters are inhibited in their action and the musculature of 
the rectum impels the fecal mass through it. 

The function of the rectum and sigmoid is for the reten- 
tion and storage of fecal matter until sufficient has accumu- 
lated and the time is convenient for its discharge. 

The movements of the large and small intestines are 
similar, except that in the former they are more infrequent, 
so the contents are moved along more slowly and become more 
solid from the absorption of the fluid portion, until in the 
form of faeces it reaches the sigmoid colon and rectum. 
Cannon, from his studies of the normal movements in cats, 
as seen by the Rontgen rays (Howell's " Text-Book of Phys- 
iology," page 649), comes to the conclusion that movements 
in the large intestine show a marked peculiarity previously 
overlooked. He divides the large intestine into two parts; 



22 DISEASES OF ANUS, RECTUM, AND SIGMOID 

in the second, corresponding roughly to the descending colon, 
the food is moved toward the rectum by peristaltic waves. A 
number of constrictions may be seen simultaneously within a 
length of a few inches, whereas in the ascending and transverse 
colon and caecum the most frequent movement is that of anti- 
peristalsis. The food in this portion of the canal is more or 
less liquid, and its presence sets up running waves of con- 
striction which, beginning somewhere in the colon, pass toward 
the ileocecal valve. These waves occur in groups separated 
by periods of rest. The presence of the ileocecal valve pre- 
vents the material from being forced back into the small intes- 
tine. The value of this peculiar reversal of the normal move- 
ment of the bowels, at this particular point, would seem to lie 
in the fact that it delays the passage of the material toward 
the rectum, and by thoroughly mixing it gives increased oppor- 
tunities for the completion of the processes of digestion and 
absorption. As the colon becomes filled some of the material 
penetrates into the descending part, where the normal peri- 
stalsis carries it toward the rectum. Howell says, " the large 
intestine, particularly the descending colon and rectum, 
receives its nerve-supply from two sources : ( i ) Fibres which 
leave the spinal cord in the lumbar nerves (second to fifth in 
the cat) pass to the sympathetic chain, and thence to the 
inferior mesenteric ganglia, which probably forms the termina- 
tion of the preganglionic fibres. From this point the path is 
continued by fibres running in the hypogastric nerve and 
plexus. Stimulation of these fibres has given different results 
in the hands of various observers, but the most recent work 
indicates that they are inhibitory. (2) Fibres that leave the 
cord in the sacral nerves (second to fourth) form part of 
the nervi erigentes, and enter into the pelvic plexus. When 
stimulated these fibres cause contractions of the muscular 
coats ; they may be regarded, therefore, as motor fibres. As 
in the case of the small intestine and stomach, we may assume 
that these motor and inhibitory fibres serve for the reflex 
regulation and adaptation of the movements." 



ANATOMY AND PHYSIOLOGY 23 

Defecation. — When the faeces reach the sigmoid colon and 
rectum, the nearly solid material stimulates by its pressure 
the sensory nerves of the rectum and produces a distinct 
sensation and a desire to defecate. 

As stated, the internal sphincter is a strong band of plain 
muscular fibres, formed by an aggregation of the circular mus- 
cular coat of the rectum, hence composed entirely of involun- 
tary fibres. When the rectum contains fecal material this 
muscle seems to be thrown into a condition of tonic contraction 
until the act of defecation begins, when it is relaxed. The 
internal sphincter is innervated by fibres having the general 
course given above for the nerves of the large intestine. The 
external sphincter ani is composed of striated muscle fibres and 
is under the control of the will to a certain extent. 

When, however, the stimulus from the rectum is sufficiently 
intense, voluntary control is overcome and this sphincter is 
also relaxed. The act of defecation is in part voluntary and in 
part involuntary. The involuntary factors are found in the 
contractions of the strongly-developed musculature of the 
rectum, especially the circular layer which serves to force the 
faeces onward, and the relaxation of the internal sphincter. 
It would seem that these two acts are mainly caused by reflex 
stimulation from the lumbar spinal cord, although it is prob- 
able that the rectum, like the rest of the alimentary tract, is 
capable of automatic contractions. The rectal muscles receive 
a double nerve-supply, containing physiologically both motor 
and inhibitory fibres. The former come probably from the 
nervus erigens by way of the pelvic plexus; the latter from 
the lumbar cord through the corresponding sympathetic gan- 
glia, inferior mesenteric, ganglion, and hypogastric nerve. It 
has been asserted that stimulation of the nervus erigens causes 
contraction of the longitudinal muscles and inhibition of the 
circular muscles, while stimulation of the hypogastric nerve 
causes contraction of the circular muscles and inhibition of 
the longitudinal layer. This division of activity has not been 
confirmed by recent experiments. 



24 DISEASES OF ANUS, RECTUM, AND SIGMOID 

The voluntary factor in defecation consists in the inhibi- 
tion of the external sphincter. Although the act of defecation 
is normally initiated by voluntary effort, it may also be aroused 
by a purely involuntary reflex when the sensory stimulus is 
sufficiently strong. Goltz has shown that in dogs in which 
the spinal cord had been severed in the lower thoracic region, 
defecation was performed normally. In later experiments, in 
which the entire spinal cord was removed, except in the cer- 
vical and upper part of the thoracic region, it was found that 
the animal,, after it had recovered from the operation, had 
normal movements once or twice a day, indicating that the 
rectum and lower bowels acted by virtue of their intrinsic 
mechanism. An interesting result of these experiments was 
the fact that the external sphincter suffered no atrophy, 
although its motor nerve was destroyed, and that it eventually 
regained its tonic activity. 

It would seem that the whole act of defecation is, at best, 
an involuntary reflex. The physiological centre for the move- 
ment probably lies in the lumbar cord and has sensory and 
motor connections with the rectum and the muscles of defeca- 
tion, but this centre is probably provided with connections with 
the centres of the cerebrum, through which the act may be 
controlled by voluntary impulses and by various psychical 
states, the effect of emotions upon defecation being a matter 
of common knowledge. In infants the essentially involuntary 
character of the act is well known (Howell, pp. 650, 651). 

It will be seen that of the two sphincter muscles that guard 
the anal outlet to the rectum, the internal is entirely under 
the control of sympathetic impulses; these in turn are under 
the influence of a centre in the lower portion of the lumbar 
cord, which is influenced under normal conditions either by 
impulses through these reflex fibres or by impulses from the 
cerebral centre above. This lumbar centre may also be influ- 
enced by strong reflex impulses through peripheral nerves. 
The external sphincter is a striated muscle and is supplied by 
cerebrospinal nerves, viz., the inferior hemorrhoidal and the 



ANATOMY AND PHYSIOLOGY 25 

deep division of the anterior perineal nerve, both of which are 
branches from the pudic nerve, which in turn is made up from 
branches from the second, third, and fourth sacral nerves. 
The external sphincter is, therefore, to be reckoned as a volun- 
tary muscle, but from what follows it will be seen that this 
muscle is a notable exception to the rule, and possesses certain 
characteristics of both voluntary and involuntary muscle-fibre. 
For instance, the sacral fibres through which it is supplied are 
under the influence of the same centre in the lumbar cord as 
that which influences the internal sphincter. This centre, as I 
pointed out, is also influenced by the cerebral centre, and, 
certainly, so far as the external sphincter acts under the latter's 
control, is a typical voluntary nerve ; but, when separated from 
this cerebral centre, it acts just as well, only automatically 
under the control of the lumbar centre. Therefore the local 
nervous mechanism consisting of both cerebrospinal and sym- 
pathetic nerves which connect the two sphincters with the 
lumbar centre is complete for all purposes and can carry out 
the functions of the rectum and anus without control and 
supervision from the higher centres. This will be further seen 
by reference to the researches of Frankl-Hochwart and Froh- 
lich on the tonus and innervation of the sphincters {PHeger's 
Archives, vol. lxxxi, p. 420). They quote a number of facts 
which indicate that the properties of the external sphincter 
resemble those of plain muscle. For example: (a) It shows 
no degeneration after destruction of the cord, thus differing 
from ordinary striated muscle (Goltz). (b) It shows no 
degeneration after section of the sacral branches, constituting 
the origin of its motor nerves (Arlving and Chautre). (c) Its 
curve of contraction (when stimulated through its nerve) 
differs from the usual skeletal muscle, in having a longer 
latent period, and slower contraction and relaxation. (d) 
(Their own experiment.) It is not paralyzed by curare any- 
thing like so rapidly as ordinary striated muscle. 

As already stated in speaking of their functions, the rectum 
and sigmoid are the receptacles for fecal matter, it being, 



26 DISEASES OF AXUS, RECTUM, AND SIGMOID 

however, more constantly present in the latter than in the 
former. I cannot, however, concur in the belief formerly 
expressed, that the rectum is always empty except just before 
defecation, or with the theory of O'Beirne " that the fecal 
matter is lifted back into the sigmoid by a retroperistaltic 
action after it has remained in the rectum for a short time." 

As generally known, absorption of fluids and nutrient mate- 
rial still continues to take place in the sigmoid and rectum 
through the glands of Lieberkiihn; consequently, whenever 
fecal material is detained for some time in the sigmoid and 
rectum it becomes much drier and firmer. By reason of this 
property the rectum and sigmoid are used for the administra- 
tion of nutrient enemas and certain drugs. But, in the use 
of either, it should be remembered first to clear the bowel of 
fecal matter, and next to administer the injection with the hips 
well elevated, in order that it may be distributed over as large 
a surface as possible. 



CHAPTER II 
EXAMINATION 

The importance of a thorough examination of the anus, 
rectum, and sigmoid cannot be over-estimated, and I would 
impress upon every general practitioner the advantages to be 
gained therefrom and the great reflection upon himself and the 
profession that follows its neglect whenever occasion requires. 
Unfortunately, it far too frequently happens that a case is 
sent to a specialist by a general practitioner either not exam- 
ined at all, or in a most casual and unsatisfactory manner. 
It would seem that there is as much (if not more) dislike for 
such examination on the part of the attending physician as on 
the part of the patient, whose own diagnosis is accepted and a 
prescription given without any further examination. This 
practise cannot be' too strongly condemned, as it is perfectly 
feasible for every physician to have the few necessary instru- 
ments, the most important being the index finger. 

History. — The first thing to be done when a patient pre- 
sents himself is to obtain a clear and distinct history of the 
trouble for which he seeks advice, with a succinct relation of 
all the symptoms complained of. The family history, as well 
as the personal history of the patient, will frequently throw 
much light upon the case, and sufficient time should be taken 
to obtain this data. Before proceeding to make a physical 
examination, it is necessary that the rectum and sigmoid should 
be emptied of their fecal contents by enemas of tepid water, 
w r hich can be administered in the physician's office if the con- 
veniences are at hand, or the patient can be given a purgative, 
with instructions to return the following day. 

Position — Left Lateral or Sims's. — The best position 
in which to place a patient for an ordinary examination of the 
rectum is the left lateral of Sims, with the hips elevated and 

27 



28 DISEASES OF ANUS, RECTUM, AND SIGMOID 

the shoulders and head lowered to form an angle of from 15 to 
20 degrees. This position is probably the most convenient for 
the examiner and entails less exposure to the patient. It can 
be done on an ordinary office table, or on one of the many 
special chairs or tables made for this and gynaecological 
purposes. 

Knee-Chest Position. — Another position that offers 
special advantages particularly for the upper portion of the 




Fig. 9. — Knee-chest position. 

rectum and sigmoid is the knee-chest position, which appar- 
ently is not properly appreciated, being seldom used by any 
except specialists (Fig.9). To obtain the advantages offered by 
this position it is very necessary that certain rules be adhered 
to. The table on which the patient is placed should be of such 
a height that when the position is assumed the anus should 
either be slightly below or on a level with the eyes of the 
examiner. The thighs of the patient should be at right angles 



EXAMINATION 29 

with a line drawn through the acetabula, his chest in direct 
contact with the surface of the table, the arms being spread 
out and the head turned to one side, so as to allow the side of 
the face also to rest upon the surface of the table. This posi- 
tion empties the pelvis of a large portion of the sigmoid and 
all of the intestines and relieves the rectum of pressure from 
the adjoining organs, so that when the anus is opened with a 
single-bladed speculum or proctoscope the air will rush in and 
balloon the rectum, as is the case with the vagina under simi- 
lar conditions. 

Mathews and Hanes, of Louisville, Kentucky, have devised 
a table for the examination of patients in the inverted position. 
I give a description of position and table by Dr. Mathews and 
the cause that led to it from the " Transactions of the Amer- 
ican Proctologic Society," 1908, p. 36. 

" The circumstances which led to the use of this position 
were met with in a patient whom Dr. Hanes was treating for 
a tubercular lesion in the upper portion of the rectum. This 
patient had an unusually long sacrum and coccyx, with the 
curve of each much exaggerated. Hanes found it very diffi- 
cult to make local applications to the lesion through the proc- 
toscope with the patient in the knee-chest posture. When the 
instrument was introduced, the distal end, in following the 
hollow of the sacrum, was pointing upward when the lesion 
was brought into view, which made it necessary to get under 
the proximal end of the instrument to view the bowel, often 
imperfectly distended. This was an exceedingly awkward 
position. If it were desired to pass a liquid agent into the 
bowel it would immediately return. By gradually inverting 
the patient, from time to time, it was found that the view and 
means of treatment were correspondingly improved until it 
was ascertained that the maximum amount of good could be 
obtained by completely inverting the patient. Finding- such 
material advantage in the employment of this position in this 
case, we took occasion to practise it on other cases. It is not 
difficult to see that in this posture the abdominal viscera will 



SO DISEASES OF ANUS, RECTUM, AND SIGMOID 

more completely gravitate toward the diaphragm and, there- 
fore, the sigmoid and rectum will be drawn upon and brought 
more nearly in the direction of a straight line. This aids 
materially in ballooning the bowel and, therefore, renders 
more easy the introduction of the instrument. Again, the 
surgeon is in an absolutely easy position, standing as he does 
over the patient, looking directly down into the bowel ; and in 
making topical applications to any part of the rectum and 
sigmoid it is done with perfect ease and comfort to the sur- 
geon. There is not a more successful way known by which 
a high enema may be given. The water is poured into the 
proctoscope as though it were a funnel. When it is necessary 
in our office to give an enema, especially where we wish the 
solution to pass into the sigmoid, we always employ this posi- 
tion. It is done with the greatest ease and there is no doubt 
about the water passing into the sigmoid and colon. And, 
again, it is very often desirable to pass a small quantity of a 
solution of some kind to a definite point in the sigmoid or 
rectum; and this can be done with absolute precision by the 
employment of this position." 

"By the use of our table (Fig. 10) the patient can take 
a standing position in front of it and, leaning slightly forward, 
be thrown into a completely inverted position without any 
effort upon his part. He is firmly supported and feels thor- 
oughly secure in this posture, and when the treatment is com- 
pleted, the patient is brought back to a standing position by 
reversing the movements of the table." 

Exaggerated Lithotomy Position. — Another position 
which is preferred by some, and which possesses certain advan- . 
tages, is the exaggerated lithotomy position (Fig. n), in 
which also the patient's hips should be elevated, the head and 
shoulders lowered, the thighs acutely flexed over the abdomen, 
with the legs acutely flexed on the thighs. This position is 
the one generally used for operations and has certain advan- 
tages in making examinations; sometimes the sigmoidoscope 
can be introduced in this position when it has failed to enter 



EXAMINATION 



31 



its full length in Sims's or the knee-chest position. It also 
offers the opportunity in females of ascertaining the relation 
of the uterine organs to the rectum. 



^sigg^ 




Fig. ioa.— Mathews and Hanes exam- 
ining table for the inverted position. 



Fig. iob. — Showing the table inverted. 




Fig. ioc. — Showing the patient in position 
on the table. 



—Showing the patient and table 
inverted. 



External Appearances. — Having placed the patient in posi- 
tion, the external appearance of the anus and its immediate 
surroundings should be carefully noted : Is the anus pro- 
truding or retracted and funnel-shaped? the epidermis dry or 



32 DISEASES OF ANUS, RECTUM, AND SIGMOID 

moist, inflamed or excoriated? are any parasites or pediculi 
present ? and specially note if there are any fistulous openings, 
sometimes so small as only to be seen with great difficulty, or 
external growths, swellings, ulcerated surfaces, or protrusions. 
The buttocks should then be pulled well apart and the patient 
requested to bear down, which will bring into view most of the 
anal canal. 




Fig. ii. — Lithotomy position. 

Digital Examination. — The information to be gained 
by touch, through a well-educated index finger, for the first 
four inches of the rectum, is probably greater than by any 
other means. The finger should be well lubricated and carried 
in by a slow, steady, and gentle pressure, but if the anus is 
very sensitive and irritable, where a fissure is present, this 
form of examination had better be omitted until the patient is 
etherized. The lubricant should be kept in a collapsible tube 
to avoid infecting it by soiled fingers, as may happen when 
it is kept in jars. The character of the information to be 



EXAMINATION 33 

gained by digital examination is varied and far-reaching, such 
as being able to recognize the presence of enlarged papillae, 
growths, and ulcerations where they have involved the deeper 
tissues, indurations, either localized or general, the internal 
opening of a fistula, if large or raised, foreign bodies, stric- 
tures, and procidentia recti. The characteristics of growths 
and the extent to which they involve the rectal walls or 
adjoining organs can be appreciated much better by this means 
than by any other. 

The Introduction of the Hand into the Rectum. — 
Since the feasibility of this procedure was demonstrated by 
Simon, of Heidelberg, in 1872, the advisability of examining 
the large bowel high up by this means has been very seriously 
questioned, and Tuttle has reported four cases in which death 
followed the operation. This author believes that a hand that 
requires a kid glove larger than 7% should never be introduced 
into the rectum except in an emergency involving life or death. 
It should always be done under the influence of a general 
anaesthetic and only when the coats of the bowel are in a 
healthy condition, as, for instance, for the extraction of foreign 
bodies, or fecal impaction, or for exploring the pelvic cavity. 

Necessary Appliances. — Table. — Probably the best all- 
round and most convenient table is that made by the W. D. 
Allison Company (Fig. 12). I find this most convenient, 
more presentable, occupying less space, and more easily moved 
than the chairs generally used. 

Instrument Cabinet. — It is also well for the doctor to 
have in his office an instrument cabinet for the convenience 
of having instruments, solutions, and basins ready at hand; 
for preservation of instruments, and for the good impression 
such neatness and conveniences make. A very convenient 
cabinet is that made by the W. D. Allison Company (Fig. 13). 

Light. — Since the introduction of the pneumatic procto- 
scope and sigmoidoscope the subject of artificial light for 
rectal examinations has been satisfactorily solved. A storage 
3 



34 DISEASES OF AXUS, RECTUM, AND SIGMOID 

battery not only answers every purpose for lighting the small 
lamp of the proctoscope but is really better than the street 
current, which is so likely to burn it out. When a proctoscope 




Fig. 12 — W. D. Allison's examining table. 




Fig. 13. — W. D. Allison's cabinet. 



is not obtainable, a head-mirror for reflected light will prob- 
ably serve the best purpose; this is also more likely to be 
readily available. 



EXAMINATION 35 

Specula. — The choice of a speculum will depend first upon 
the portion of the canal to be examined. If only a part or the 
whole of the anal canal, I certainly prefer a single-bladed one 
specially constructed to meet the conditions. While its 
mechanism on general principles should be similar to Sims's 
vaginal speculum, it must be more pointed at the end, much 
more distinctly curved from tip to base, narrower from side to 
side, and more deeply curved in its cross section, or, to put it 
clearer, with higher sides, in order to prevent the rectal folds 
from protruding over the sides of the speculum. Such an 
instrument I had made some ten or twelve years ago (Fig. 14) . 




Earle's. single-blade speculum. 



This is specially adapted for the examination of fissures, 
when only the tip is introduced to pull back the opposite anal 
wall; also for irrigating the rectum preparatory to an opera- 
tion after the patient has been placed under the anaesthetic. 
Here it can be turned in any direction while scrubbing the 
opposite wall ; at the same time it serves the purpose of dilating 
the sphincters. A Sims speculum may be made to answer the 
same purpose, but is not nearly so satisfactory. Dr. Dwight 
H. Murray has recently devised a very good one (Fig. 15) 
which has the merit of being introduced with little discomfort 
to the patient; and of being withdrawn without added dis- 
comfort, allowing a good view of the part to be examined, and 
of being easily cleaned and sterilized. 



36 DISEASES OF ANUS, RECTUM, AND SIGMOID 

For higher examinations in the rectum and sigmoid the 
pneumatic proctoscope and sigmoidoscope are par excellence 
the best. Those designed by Laws and Tuttle are preferable, 
the latter being more recent in construction and correcting 
some defects of the former. They both have an electric illu- 
mination stem which carries the light to the far extremity of 
the proctoscope. In Tuttle 's instrument the stem for carrying 
the light is run in a groove external to the lumen of the tube, 




Fig. 15. — Murray's speculum. 



thereby not interfering with its calibre or with the view to be 
obtained through it. In both the extreme end of the cylinder 
for the light is protected by a flint glass bulb, guarding the 
light from the intestinal discharges and at the same time not 
interfering with illumination. Tuttle's instrument is made in 
several lengths from four to fourteen inches and varying in 
diameter from seven-eighth to one and one-fifth inches. The 
four-inch instrument is long enough for all examinations of 
the rectum, the ten-inch instrument for the rectum and lower 
portion of the sigmoid, while the fourteen-inch instrument is 



EXAMINATION 



37 



only necessary in persons with long sigmoids or loose meso- 
colons, and for the purpose of seeing into the lower portion 
of the descending colon (Fig. 16). 

The Limit of Ocular Examination. — While reference 
has been made to the possibility of examining into the descend- 
ing colon, Tnttle and Abbott have both shown by numerous 
experiments on the cadaver that this cannot be done. Accord- 
ing to Abbott, of Minneapolis, Minnesota (American Gyncec. 
and Obstet. Jour., July, 1900, p. 20), a straight tube passed 




Fig. 16. — Tuttle's pneumatic proctoscope (Tuttle) Appleton. A, obturator; B, plug 
with glass window closing end of tube; C, handle; D, cords connecting instrument with 
battery; E, inflating apparatus; F, main tube of proctoscope. 

further than twelve inches would impinge against the liver or 
diaphragm; therefore a twelve-inch proctoscope is the longest 
permissible. 

Each of these instruments is provided with an obturator 
for the purpose of its easy introduction beyond the sphincters. 
This should be done in Sims's position for rectal examination, 
and in the knee-chest position for examination of the sigmoid. 



38 DISEASES OF ANUS, RECTUM, AND SIGMOID 

In Turtle's instrument a plug, ground to fit air-tight, is 
inserted in the proximal end when the obturator is withdrawn. 
This plug contains a plain glass window, or a lens focused to 
the length of the instrument to be used. The cavity of this 
plug is connected by a small tube which enters it at a position 
adjoining to the inner side of the glass window and is for the 
purpose of connecting its cavity and the cavity of the procto- 
scope with a hand-bulb for inflation of the rectum. As soon 
as the obturator is withdrawn the plug is introduced and by 
gentle inflation with the hand-bulb the rectum is dilated ahead 
of the instrument, which is gradually introduced, the electric 
light being turned on and the inspection of the rectal walls 
made as the instrument passes slowly up; care should be 
taken to use no undue force either in pushing the instrument 
in or in over-distending the rectal walls by inflation. (A 
full description and the instrument can be obtained from 
the Electrosurgical Instrument Company, Rochester, N.Y.). 
When necessary to make an application to an ulcer on the 
rectal wall, the spot should be directly in front of the end of 
the proctoscope, the plug at the proximal end removed and 
the application made with long forceps through the procto- 
scope. In this manner successive ulcers can be treated at the 
same sitting. To avoid condensation of moisture on the 
glass window of the plug, which occurs during prolonged 
examinations and materially obstructs the view, the plug itself 
should be dipped in hot water before being inserted in the 
end of the proctoscope. 

Dr. J. Rawson Pennington, Chicago, Illinois, has devised 
a very good tubular bivalve speculum obviating the difficulties 
of the ordinary bivalve rectal speculum, as it possesses an 
obturator which enables it to be used primarily as a tubular 
speculum by withdrawing the obturator and subsequently, if 
necessary, as a bivalve (Fig. 17). It was designed more 
specially for a dressing speculum. 

Dilators. — I think that of the different methods recom- 
mended for rapid dilatation, probably the best mechanical one 



EXAMINATION 



39 



is the metallic conical dilator devised by Dr. Howard A. 
Kelly (Fig. 18). Dilatation by the fingers is a time-honored 
method, perfectly safe and efficient. 




Fig. 17. — Pennington's bivalve speculum. 



/••• •_; ■ ■"" 





Fig. 18. — Kelly's graduated conical dilator. 



For the gradual or rapid dilatation of the anal canal the 
dilatable rubber bags (Fig. 19) suggested and described by 
Dr. Dudley Roberts, Brooklyn, New York, are excellent. 



40 DISEASES OF ANUS, RECTUM, AND SIGMOID 

The advantages of a dilatable bag for overcoming the con- 
traction of the uterine cervix are well known. Such dilata- 
tion is under the entire control of the operator; it may be as 




Fig. 19. — Dudley Roberts's rubber bag dilators. 

gradual and as distensive as demanded. The force is exerted 
in the proper direction, not pushing the tissues ahead of a 
dilating instrument. 



EXAMINATION 41 

The instrument shown in the accompanying illustration 
(one-half actual size) has been under trial for many months 
and in that time has proved to me that failures of gradual 
dilatation have been due to intrinsic faults of former instru- 
mental methods. Patients who had been- subjected formerly 
to treatment with the largest size rubber bougies, having a 
circumference of 9 cm., have been better able to stand dilata- 
tion with this bag expanded to the full size, a circumference 
of 14 cm. at the constricted portion. It seems to be perfectly 
feasible to accomplish gradual dilatation of the anus to the 
necessary degree with comparatively little discomfort. The 
induced anaemia of the tissues pressed upon must contribute 
to this analgesia. The muscle is gradually tired out and 
relaxes just as the fingers must if an effort is made to hold 
the bag against expansion. The smoothness of the instrument 
obviates any tendency to spasm during introduction. With- 
drawal causes no dragging on the mucous membrane. 

The apparatus consists of an inner bag of rubberized cloth, 
the ends made bulbous to prevent slipping inward or outward 
when distended. To this bag is attached a tube of like material 
on the end of which is fastened a small stop-cock and a hand- 
bulb, valved to prevent the backward passage of air, is attached 
to it. Within the bag and extending through a portion of the 
tube is a slender metal rod with bulbous ends ; a simple means 
of giving the collapsed bag sufficient rigidity during introduc- 
tion. Outside the strong dilating-bag is a thin elastic cover 
free from seams, which gives a perfect smoothness to the bag 
at all stages of dilatation. The seams and wrinkles of the 
inner bag are not perceptible through this cover. 

The method of use is exceedingly simple and few directions 
are necessary. The condition of the valves in the hand-bulb 
must be determined, as back leaks make dilatation impossible. 
The number of slight " squeezings " necessary to fill the bag- 
is a matter of individual experimentation, also the tension 
indicates when the bag is full and further distention impossible. 
Let the bag be well dusted with talcum powder or covered with 



42 DISEASES OF ANUS, RECTUM, AND SIGMOID 

an emollient, the elastic cover slipped on and turned around to 
completely lubricate apposed surfaces. Two-thirds of the 
length of the bag are introduced, the bulbous portion protrud- 
ing from the anus, and slow dilatation is started. When dis- 
comfort is caused the stop-cock is turned and a few minutes 
allowed to elapse in order that voluntary and involuntary 
spasm may be relaxed. Gradually the dilatation is continued, 
and when as much as possible has been secured the bag is left 
in place for ten to fifteen minutes. The patient is instructed 
to lie flat on the back and relax completely. Successive treat- 
ments follow and each time dilatation is found to be easier, 
until a normal condition is established. 




Fig. 20. — Rectal curette. 

The advantage of this form of instrument in the treatment 
of strictures of the rectum above the anus is well seen. 
Through a speculum the bag is introduced and placed in the 
desired position, when stretching to the necessary degree is 
readily accomplished. 

A larger size than that shown in the cut is necessary in 
some instances, and to meet this demand I have had one con- 
structed without the central constriction ; this has a circumfer- 
ence of 18 cm. throughout, the smaller one measuring 14 cm. 
in the central portion and 16 cm. at the bulbous ends. The 
same sized cover answers for both bags. 

Applicators and Dressing Forceps. — The instruments 
used for making applications to anus or rectum should be 
sufficiently long to be used for similar applications up in the 



EXAMINATION 



43 



rectum through the average length proctoscope. Long dress- 
ing forceps and curette with which to make scrapings 
from ulcers (Fig. 20) should be among the instruments 
found on a doctor's table. He should also possess a pair of 
Bransford Lewis 12-inch alligator forceps (Fig. 21), that 
may be used through the longest proctoscope for the abstrac- 
tion of foreign bodies ; these are specially applicable in catch- 
ing and twisting off small multiple polypi and a most neces- 
sary part of his armamentarium. 




Fig. 21. — Alligator forceps. 



■3C 



Fig. 22. — Silver probe. 



Fig. 23. — Grooved directors. 



Probes and Grooved Directors. — Several graded sizes 
of silver probes and grooved directors are also necessary (Figs. 
22 and 23). Blunt hooks of different shapes and sizes are 
useful for examining the crypts, valves, and internal blind 
fistulse of the rectum. 

Dr. Dwight H. Murray has devised a scrotal holder and 
shield which will be found most satisfactory and useful when 
operating on male patients (Figs. 24 and 25). 



44 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Bougies. — Used now principally for the dilatation of 
strictures (having been superseded by the proctoscope for 
diagnostic purposes), these should be very flexible, conical, 
cylindrical, and of graded sizes, usually from i to 12. Those 
made by Wales are of soft rubber, and are by far the best. 
The old English rectal bougie was made of web and shellacked, 
thus securing a smooth surface which by soaking in hot water 
becomes somewhat flexible ; not sufficiently so, however, to be 
used without great care. In fact, all bougies should be used 
with such care, especially as the tissues in cases demanding 
their use are easily torn. I do not recommend the metallic 
vertebrated bougies. The instrument should be thoroughly 
lubricated before introduction and passed very gently upward 




Fig. 24. — Murray's scrotal- holder and shield. 

until an obstruction is met, when an ordinary Davidson bulb 
or fountain syringe is attached to the proximal end and the 
water allowed to flow in through the small lumen; this will 
push out of the way any folds of mucous membrane or masses 
of fecal matter. This is seldom necessary in cases to which 
the use of the bougie is now restricted, viz., strictures in which 
there are no redundant folds, unless the stricture is very high 
up and here its use is contraindicated. 

In making examinations where there are neoplasms, let a 
specimen be removed for microscopic examination for a cor- 
rect diagnosis. In all obscure conditions, a careful macro- 
scopical and microscopical examination of the bowel should 
be made, and also a bacteriological examination of discharges 
from the bowel. 



EXAMINATION 



45 



Examination of the Faeces. — A microscopical, bacterio- 
logical, and chemical examination of the faeces should not, I 
think, be explained in a work on diseases of the anus and 
rectum; it belongs more properly to general medicine and to 
the gastro-enterologists. A macroscopical examination of the 




Fig. 2 5 .— Mu 



;'s scrotal-holder and shield in position. 



faeces assists materiall)' in diagnosing intestinal obstructions 
low down, by the shape of the fecal masses when moulded, or 
the presence of ulcerations, malignant or benign, and of pus, 
blood, or mucus in the fecal discharges. When special forms 
of ulceration exist our diagnosis should be made upon micro- 



46 DISEASES OF ANUS, RECTUM, AND SIGMOID 

scopical examinations of the scrapings from the ulcers rather 
than the faeces. The consideration of such examinations I 
will take up later. 

The number of evacuations in normal individuals varies 
from one to three in twenty-four hours, or one in forty-eight 
to seventy-two hours, in the latter interval without any 
apparent ill-effects, local or general. It is better, however, to 
advise these patients to overcome such a habit and to have a 
stool daily, as the continuation of such a torpid condition of 
the bowels will likely lead to bad results in the end. While 
the stool of a healthy person may be either moulded or mushy, 
yet there is a condition of consistency in the stool of persons 
who are perfectly regular in the daily evacuations of their 
bowels that will frequently furnish an explanation for abnor- 
mal lesions, such as a. fissure or eroded and bleeding internal 
hemorrhoids. I allude to a very dry and hard condition of 
the first portion of the stool, which requires so much effort 
to' move it and is so dry as to give rise to the trouble above 
mentioned. The recommendations for the relief of this trouble 
will be considered under the head of Constipation. 

The presence of foreign matter that has been taken in 
with the food and passed out with the faeces need only be 
referred to, to warn the physician against mistaking it for 
living organisms or the dead remains of such. To avoid such 
a mistake it will frequently be necessary to resort to the use 
of the microscope. 

Enteroliths are sometimes found in the faeces. They are 
intestinal calculi and concretions, the nature of which will be 
considered hereafter. Attention is called to them here, in 
treating of a macroscopical examination of the faeces, that 
they may be recognized when seen. 

The mucus, which in normal conditions is secreted only in 
sufficient quantities to serve as a coating to the bowel, may be 
very much increased, and discharged in considerable amounts, 
in various pathological lesions of the intestines, both large and 
small. When present in such undue quantities a special 



EXAMINATION 47 

investigation as to its cause and origin is indicated. The 
special causes giving rise to it and the evacuation of blood or 
pus will be considered under special headings, though the 
blood from very low down or very high up in the bowel differs 
so materially in macroscopical appearance that it may be well 
to refer to it here more in detail. This distinction may always 
be made : When it is bright red its origin is always low 
down, at or near the anal margin, and when dark purple or 
nearly black, the latter often being of a tarry consistency, 
the source of the bleeding is always high up in the bowel, its 
extrusion being thereby delayed and time given for the changes 
in its normal characteristics above noted. 

The presence of parasites, vegetable cells, muscular fibre, 
oil globules, and fibrous tissue may all be recognized by the 
naked eye, but may require the aid of the microscope for 
differentiation. 

The examination hitherto alluded to can generally be made 
with proper care and patience without giving rise to much 
pain or calling for the aid of an anaesthetic, but frequently 
the anus may be so hyperaesthetic and irritable as to demand 
the use of local or general anaesthesia. It is far better that 
the physician should recognize this readily, without persistent 
efforts to make such an examination. As a rule he can gain 
from the history and symptoms sufficient knowledge of the 
existing condition to be prepared to do any minor operation 
while the patient is under the anaesthetic for the examination. 
It is generally better for him to postpone the examination 
until he can do both. 

Anaesthesia in Rectal Disease. — While many minor opera- 
tions on the anus and rectum, including the forcible dilatation 
of the sphincters, can be done with perfect satisfaction under 
local anaesthesia when used with the improved technic of Tuttle 
and Gant, yet in the majority of rectal operations it will be 
found more satisfactory to use general anaesthesia, unless 
specially contraindicated. The sensibility of the parts is so 
acute that it is very difficult to overcome all resistance offered 



48 DISEASES OF ANUS, RECTUM, AND SIGMOID 

by the sphincters, hence there are frequently pathological con- 
ditions which should be removed that are overlooked when 
local anaesthesia is used. 




Fig. 26. — Showing perineal nerve supply for local anaesthesia. 

Local Anesthesia. — The best for use in this locality 
are weak solutions of cocain or beta-eucain, from ]/^ to ^2 
of 1 per cent., freshly made and sterile. Tuttle's technic is as 



EXAMINATION 49 

follows (Fig. 26) : An hypodermic needle two inches in length 
is introduced in the median line one-half inch back of the pos- 
terior commissure of the anus, and a drop or two of the solution 
is injected into the subcutaneous tissue ; the right index finger 
is then introduced into the rectum and hooked around the 
internal sphincter, thus dragging it down into apposition with 
the external; the needle is then carried upward and forward 
into the sphincters one after the other, depositing about 
5 m. of the solution in each muscle at a point about one-half 
inch in front of the posterior commissure ; the needle is then 
easily withdrawn and introduced in a like manner into the 
muscle on the opposite side of the posterior commissure; 20 
to 30 m. of the solution in all are used. After about two or 
three minutes Earle's single blade speculum is introduced into 
the anterior commissure of the rectum, and with this as a point 
of resistance the sphincters are gently massaged and stretched 
to any desirable extent. I do not claim that the sphincters 
can be divulsed, or the perirectal tissues torn down by this 
method without pain, but I do maintain the sphincters can be 
stretched sufficiently for all practical work under local anaes- 
thesia. Over one hundred cases have been operated upon by 
myself and my associate, Dr. Lynch, up to this writing, with 
practically no failures, and the method has been demonstrated 
to a large number of visiting doctors during the past six 
months at the Polyclinic Hospital. The points in which I 
claim originality are the single puncture, thus minimizing the 
dangers of infection and the localization of the sensitive nerves 
of the sphincter. After the sphincter is stretched the hemor- 
rhoids or ulcers should be anaesthetized with a mild solution 
(yi to V10 P er cent - °f the drug employed), as the anaesthesia 
has not extended to the cutaneous margin of the anus in the 
anterior quadrants. In fissure no second puncture is necessary, 
as the first usually suffices. The class of cases to which this 
method of anaesthesia is applicable includes those very sensi- 
tive and painful conditions in which a satisfactory examination 
cannot be made without some form of anaesthesia. — viz., dila- 
4 



50 DISEASES OF ANUS, RECTUM, AND SIGMOID 

tation of the sphincters, incision and dissecting out of fissures, 
opening up fistulous tracts, removal of polypi, removal of 
hemorrhoids by almost any method except Whitehead's, in 
fact all minor operations on the anus and rectum. 

The propriety and advisability of doing many of these 
operations under local anaesthesia in the office is very ques- 
tionable, unless the patient is allowed to recline for an hour 
or more after the operation before being allowed to leave. 

A well-grounded objection to the use of local anaesthetics 
in many of these operations is the fact that the distention of 
the tissues by the injection, necessary in order to obtain thor- 
ough anaesthesia, so distorts the parts to be removed, also the 
tissues that are to remain, that it frequently happens an 
insufficient amount is taken away, resulting in necessity for 
second operation. Hemorrhage is also more likely to follow 
local anaesthesia by cocain, due to its raising the blood- 
pressure. 

I cannot do better here than quote from an article in the 
Journal of the American Medical Association, October 23, 
1909, on " Quinin and Urea Hydrochlorid as a Local Anaes- 
thetic," by Arthur E. Hertzler, M.D., Ph.D., Associate Pro- 
fessor of Surgery, University of Kansas; Roger B. Brewster, 
M.D., and Ford B. Rogers, M.D., Dispensary Assistant, Uni- 
versity of Kansas, Kansas City, Kansas : 

" In September, 1907, Dr. Henry Thibault, of Scotts, 
Arkansas, published a short article calling attention to the 
local anaesthetic effect of quinin and urea hydrochlorid. He 
recommended the use of a 1 per cent, solution for local injec- 
tion and from 10 to 20 per cent, for local application to any 
mucous surfaces. Aside from this article by Dr. Thibault 
and one by E. J. Brown, recommending its use in tonsillectomy, 
we have been unable to find in the literature any account of 
the use of these substances for anaesthetic purposes. 

" For some six months we have been using this drug instead 
of cocain in all local anaesthesias with the greatest satisfac- 
tion. So great has been the interest manifested in our studies 



EXAMINATION 51 

by our professional friends that we have deemed it best to 
report results up to date. Clinical experience was obtained in 
our private practice and by one of us (Rogers) at the dis- 
pensary of the University of Kansas. The experimental work 
was done in the laboratory of the Halstead Hospital 
(Hertzler). 

" We started with the I per cent, solution recommended by 
Dr. Thibault. We found, as stated by him, that a perfect 
anaesthesia is obtained which lasts from four to five hours. 
The anaesthesia is more complete than with cocain. We soon 
discovered, however, that disturbances in skin union some- 
times occurred. One of us (Hertzler) noted particularly that 
in hernia operations there was some disturbance in the healing 
of the skin wound which had not been noted after the use of 
cocain. The disturbance was not great, but the patient had 
to be kept in bed longer than after the cocain operation. The 
edges of the wound were indurated and thickened, but there 
was no pus formation. The thickening appeared to be due 
to cellular infiltration. 

" Hertzler thereupon undertook to determine experimen- 
tally the cause of the induration. Experiments performed- on 
rabbits showed that the thickening was not due to cellular 
infiltration at all, as was supposed on clinical grounds, but 
was due to a pure fibrinous exudate free from cells. This 
exudate was proved to be fibrin by Mallory's and Weigert's 
stain. The reaction appears, therefore, to be purely chemical 
in nature. The exudation of the fibrin begins to appear within 
a few minutes. In a general way it was determined that the 
amount of exudate depends on the strength of the solution 
used ; the attempt was made, therefore, to determine a strength 
of solution which would not cause the exudation of fibrin. In 
]/z per cent, solutions the exudate is less than with i per cent, 
and with %. per cent, solutions only traces can be discovered. 
To what extent this fibrinous exudate is subsequently con- 
verted into fibrous tissue has not been definitely determined, 
but apparently nearly all is absorbed. 



52 DISEASES OF ANUS, RECTUM, AND SIGMOID 

" In order to determine the subjective sensations of the 
injection and to determine the question of a possible zone of 
hyperaesthesia about the anaesthetized zone, one of us 
(Hertzler) studied the effect by the injections in the skin of 
his leg. Injections of I per cent., J-2 per cent., % per cent., 
and 1 / 6 per cent, solutions and an injection of plain water as 
controls were used in each series. The i per cent, and ^4 per 
cent, solutions gave immediate and complete anaesthesia with- 
out a particle of pain during its introduction. Within a few 
minutes there was a distinct induration. With the Y /\ per cent, 
solution, anaesthesia was not complete for a few minutes, but 
was then as complete as after the use of the stronger solutions. 
The 1 / 6 per cent, solution gave delayed anaesthesia, which after 
a few minutes was complete. In neither of these weaker solu- 
tions was induration noted on palpation. The water control 
caused intense pain on injection, and the anaesthesia, at no 
time perfect, lasted only a few minutes. There was a zone of 
hyperaesthesia one or two inches in width about the area 
injected. Curiously enough, the hyperaesthesia seemed to be 
for touch and not for pain. 

" The duration of the anaesthesia in the I per cent, and J4 
per cent, solutions was perfect for four or five days, and sen- 
sation in the y 2 per cent, strength was not restored to any 
great extent for ten days, and in the I per cent, solution 
sensation was not completely restored after two weeks. At no 
time was there the least pain, though the induration about the 
I per cent, and J / 2 per cent, solutions was yet marked at one 
and two weeks respectively. 

" The above observations were made with the solution of 
the quinin in water. When physiologic salt solution was used 
as the solvent, the induration was little or not at all marked, 
but the duration of the anaesthesia was much lessened. Hypo- 
tonic and hypertonic solutions also were used without notable 
variation. 

" The result of this experimentation indicated that the 
delayed skin union above noted was due to fibrinous exudate. 



EXAMINATION 53 

This was present in the i per cent, and the J/2 per cent, solu- 
tions but not in the Y\ per cent, solution to any notable degree. 
The %. per cent, solution seemed then, on laboratory grounds, 
to be the strength most desirable for anaesthesia in the class 
of work where speedy primary union of the skin is desirable 
and where duration of anaesthesia beyond several hours is not 
required, and clinical experience seems to bear out the labora- 
tory determinations. 

" Any operation ordinarily done with cocain can be done 
with quinin. The technic of its use is the same. As in the use 
of cocain, only those tissues known to be sensitive should be 
injected. In clean tissue the % per cent, solution seems to be 
strong enough to produce anaesthesia lasting several hours. In 
regions where primary union is not necessary, particularly 
in tissue the seat of inflammatory reaction, the stronger solu- 
tions are more satisfactory. In opening of abscesses, for 
instance, an operation for anal fistula, hemorrhoids, etc., the 
stronger solutions are the ones of choice. 

" We desire particularly to emphasize the value of the 
anaesthetic in two operations. In operations about the anus 
it is for us the anaesthetic of choice. In both fistulas and 
hemorrhoids, any of the radical operations can be performed 
with the same thoroughness as under a general anaesthetic. 
The advantage consists in the fact that the duration of the 
anaesthetic is from seven to ten days, which does away entirely 
with the after-pain ordinarily attending these operations." 

Spinal Anaesthesia. — The general enthusiasm with which 
spinal anaesthesia was hailed when first introduced only a few 
years ago has given place to doubts and fears on account of 
some unpleasant results from its use. After a very favorable 
report made to the American Proctologic Society, June, 1909, 
by Dr. Collier F. Martin, of Philadelphia, on " Spinal Anaes- 
thesia in Rectal Surgery," which embraced a series of eighty- 
seven successful cases, I decided to give Martin's technic in 
full, until seeing a report of sudden death following spinal 



54 DISEASES OF ANUS, RECTUM, AND SIGMOID 

anaesthesia, by Charles B. Reynolds, M.D., of Philadelphia, 
(American Journal of Obstetrics and Diseases of Women and 
Children, July, 1909). 

Reynolds not only reports his fatal cases but gives a full 
review of the results obtained by such men as Bier, the pioneer 
worker on spinal anaesthesia, who had one fatal case in over 
a thousand, where tropococain was used, .13 c.gm. (gr. 2), 
and others as follows : 

W. W. Babcock reports one fatal case in seventy-six, with 
an injection of alypin .064, adnephrin .00013, water 2 cc. 

Urban, one death preceded by delirium and great dyspnoea 
two days after an injection of one grain of tropococain, in a 
man thirty-one years of age ; operated upon for double inguinal 
hernia. 

Klose and Vogt in a series of experiments with spinal 
anaesthesia on 103 dogs and rabbits report changes in the 
cord, showing swelling with a chromatosis of the large motor 
cells of the anterior and lateral horns. 

F. Legueu (Paris) states he had discontinued the use of 
cocain by the spinal method on account of the danger. As a 
result of three hundred and fifty operations under stovain, 
he believes the anaesthesia is insufficient in one-seventh. Car- 
diac accidents, violent meningeal reaction, persistent para- 
plegia, and incontinence of urine may ensue in days or months 
following. 

Bruning (Gottingen) has used spinal anaesthesia with 
stovain, tropococain, or novococain in four hundred and fifty 
cases ; and seen three deaths — paraplegia with ascending pyelo- 
nephritis, arrest of respiration with death on the table, and 
cerebral hemorrhage. He also noticed persistent pain in the 
back of the legs from one to one and a-half years following 
the injection. 

Reynolds also gives other very interesting data on the 
subject of spinal anaesthesia, and after such an array of 
unfavorable reports from high authorities, and in the absence 






EXAMINATION 55 

of any personal experience, it seems to me the use of spinal 
anaesthesia for rectal surgery cannot be consistently recom- 
mended. 

General Anaesthesia. — The kind to be used in rectal opera- 
tions depends upon the nature of the operation and the type of 
patient. 

H. Warren Buckler (Maryland Medical Journal, April n, 
1908) says nitrous oxide and oxygen is the safest anaesthetic 
known, no fatalities having yet been recorded from its use. 
It would seem that the best subjects for it are those in a 
greatly debilitated condition from the ravages of disease, or 
who have some bronchial, pulmonary, renal, or cardiac lesions 
that would make ether or chloroform anaesthesia unsafe. For 
such a character of patients and for brief operations, also as 
a preliminary to ether anaesthesia, I would recommend nitrous 
oxide and oxygen. More recently S. Griffith Davis, of Bal- 
timore, has been able to hold patients under the influence of 
nitrous oxide and oxygen for an operation lasting two hours. 
In the absence of this anaesthetic or the necessary apparatus 
for administering it, the use pf ethol chloride is good, but I 
do not consider it as safe as the former. (The patients after 
nitrous oxide and oxygen are more sensitive to pain than those 
who, following ether anaesthesia, are partly dulled for hours.) 
Buckler suggests a hypodermic of J4 g r - of morphia just 
before the gas is administered, for the purpose of anticipating 
the pain. 

This latter practice I have followed for. years, giving in 
addition V100 gr. atropia sulph. and 1 / 30 gr. of strychnia, 
these for the purpose of regulating and sustaining the circula- 
tion. My reason for this is, that following all rectal opera- 
tions where any sewing has to be done the patient suffers 
great pain. In other cases I would recommend ether, which 
Buckler thinks is best administered by the vapor method 
originally devised by Junker and modified by Braun of Leipzig 
and Gwathney of New York. In brief, this method consists 
in passing a current of air through a chamber containing a 



56 DISEASES OF ANUS, RECTUM, AND SIGMOID 

uniform amount of ether and allowing the vapor thus formed 
to be inhaled by the patient. By this means the anaesthetizer is 
able to increase or decrease the strength of the anaesthetic vapor 
in a perfectly definite proportion by regulating the amount of 
air and the pressure at which it is driven through the ether. 
Where there is any contraindication for the use of ether, such 
as bronchial or renal diseases, we would recommend the use 
of chloroform by the drop method through an Esmarch 
inhaler. 



CHAPTER III 
CONSTIPATION 

Constipation is the delayed evacuation from the bowels 
of residual matter, delayed, although a sufficient quantity of 
food may have been taken and properly digested. Class and 
condition, sex and age are not prohibitive, though among 
females it is more prevalent because they are so prone to 
ailments of the generative organs and do not take sufficient 
exercise. It is not an uncommon condition in infants and 
is more frequent in old age than in adult life. 

I thought it best to give (with the author's permission) a 
synopsis of Illoway's arrangement and subdivision of this 
subject, taken from his work on " Constipation in Adults and 
Children." It is the very best work that has come under the 
writer's notice, and while it covers a large range of subjects 
it can be condensed into small space. 

While this classification covers all the principal causes 
leading to this condition, there are minor ones that will be men- 
tioned incidentally. 

Etiology. — The many causes may be grouped under four 
heads : 

1. Pathological conditions, within or without the intestinal 

tract. 

2. Abnormalities of form congenital or acquired ; disloca- 

tions of the large bowel. 

3. Foreign bodies in some portion of the bowel. 

4. Defective performance of normal physiological function. 

But for clinical purposes two groups suffice : 

Acute Constipation. 

Chronic Constipation. ■ 
The terms bear the same significance as when applied to 
similar conditions in other diseases. 

57 



58 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Acute Constipation. — Acute constipation is produced iii 
various ways : 

A. By direct obstruction of the lumen of the intestine. 

Intussusception. 

Volvulus. 

Twisting or inversion of the caecum. 

Strangulation by bands or hernias. 

Obstruction by foreign bodies. 

(a) Those introduced from without, whether by 

mouth or rectum. 

(b) Those formed within the body. 

B. By pathological changes in one or more of the tissues 

in the intestinal tract as we find, 
In acute inflammation of the large or small bowel. 
In various forms of peritonitis and in some cases of 

typhoid fever. 

C. By direct inhibition of peristaltic function through the 

nerve centre. 
Acute cerebral meningitis. 
Tubercular meningitis of acute form. 
Apoplexy. 
Acute mania. 
Various acute diseases of the spinal cord and its 

envelopes. 
Acute infectious diseases. 
Hysteria. 

D. By absence of or impairment of the quality of the bile. 

Various acute diseases of the liver. 
Cholelithiasis during the passage of the gall-stone 
through the common duct. 

E. By inhibition of diaphragmatic and abdominal muscular 

aid. 
Acute diseases of lung and pleura. 
Rheumatic diseases of abdominal muscles. 



CONSTIPATION 59 

Hyperesthesia of abdominal parietes. 
Paralysis of diaphragm and abdominal muscles. 
Acute diseases of the female genital tract. 

F. Reflexly. 

Inflammation of retained testicle. 

Phimosis (Witzenhauser, i, Munch, med. Wochschr., 

May 28, 1907). 
Some of the acute diseases of the female genital tract. 
Acute diseases of the bladder and prostate. 

G. By a combination of these various ways. 

Acute inflammations of the stomach. 
Attacks of gout. 

Chronic Constipation. — For this study it is best sub- 
divided according to the mode of its production in four groups : 

A. Chronic constipation produced by well-defined morbid 

processes. 

B. By obstruction from foreign bodies. 

C. By congenital malformation of a section of the large 

bowel or its mesentery. 

D. From impairment of physiological functioning. 

A further subdivision may be : 

A. Chronic Constipation from Disease 
I. By obstructing the lumen of the tube : 

Hypertrophy, or thickening of Houston's valves. 

Cicatricial narrowing. 

Constriction of the intestinal tract by bands. 

Cancerous disease of the large bowel. 

Tumors in the abdominal cavity pressing upon the 
bowel. 

Massive exudations of blood or of serum in the cel- 
lular tissue of the pelvis. 

Obstruction of the rectum by a retroverted uterus. 

Tumors within the rectum. 

The third degree of prolapse of the rectum. 



60 DISEASES OF ANUS, RECTUM, AND SIGMOID 

II. By impairment of the secretions poured into the 
intestines : 

Chronic liver disease when secretion of bile is defi- 
cient in quantity and quality. 

Disease of the pancreas. 

III. By inhibition of peristalsis through the nerve centres : 

Chronic diseases of the brain. 

Chronic affections of spinal cord and its envelopes. 

Chronic forms of insanity. 

Saturnine intoxication. 

Tabes dorsalis (locomotor ataxia). 

Paralysis after diphtheria. 

IV. By chronic venous congestion of the intestinal circu- 

lation. 

Organic heart disease. 

Some chronic pulmonary affection, asthma, emphy- 
sema, etc. 

V. By voluntary abstention from stool on account of pain 
caused by reason of a diseased condition of the 
rectum : 

Hemorrhoids. 

Ulcers of the rectum. 

Fissure of the anus. 

Chronic proctitis. 

Irritable and hysterical rectum. 

VI. By changes in the mucous membrane which impair its 
irritability and interfere with its physiological 
function : 

Chronic catarrh of the small intestines, whilst diar- 
rhoea is a prominent feature of catarrh of the large 
bowel. 

Membranous enteritis. 

Atrophy of a section or sections of the intestinal 
mucous membrane (after catarrhs). 



CONSTIPATION 61 

VII. By atony of the intestinal muscle produced by morbid 
conditions of the stomach or of the bowels : 
Atony of the stomach. 
Dilatation of the stomach. 

As a sequence of prolonged catarrh of the large 
bowel. 
B. Chronic Constipation from Foreign Bodies 

Foreign bodies which give rise to chronic constipation are 
such as are of gradual growth, whether the materials of which 
they are formed are excretions or abnormal formations of the 
body, or are introduced from without. 

C. Chronic Constipation Produced by Malformations 

of the Intestines 

Malformations of the intestines are most varied and may 
involve any part thereof. Those that are compatible with a 
more or less prolonged existence and that give rise to a state 
of chronic constipation are, so far as reported : ( I ) abnor- 
mally developed colon; (2) undue length or size of sigmoid 
flexure; (3) diverticula of the large bowel; (4) diaphragms 
in the large bowel. 

B. Essential Primary Atrophy of the Large Bowel. 
— Congenital arrest of development of the muscular apparatus 
of the bowel. 

C. Dislocation of the Bowels — Enteroptosis. — The 
most common form of dislocation is downward — enteroptosis. 
The parts of the intestinal tract most subject to this form of 
dislocation are the stomach, transverse colon, and sigmoid. 

D. Chronic Constipation from Impaired Physiological 

Function 

By impairment of physiological function we understand 
two very different conditions, namely, ( 1 ) perverted action ; 
(2) imperfect performance of physiological function. It is 
only to this category of constipation, and more particularly 



62 DISEASES OF ANUS, RECTUM, AND SIGMOID 

to the last subdivision thereof, that the term habitual con- 
stipation can be properly applied, for it is only under such 
conditions that a person may be constipated for a long time 
and still retain a fair condition of health. 

Constipation from Perverted Action : Spastic Constipation. 
— i. Enterospasm occurs when the normal physiological order 
of contraction of the circular and longitudinal muscular fibres 
is perverted and the contraction of both coats takes place 
synchronously and spasmodically. This contraction may be 
general or partial; the latter is more frequent and generally 
located in the large bowel. Enterospasm occurs most fre- 
quently in gastric and intestinal indigestions. 

2. Enterospasm and Atony. 

3. Spasmodic Stricture of the Rectum. — A spasmodic 
contraction of the rectum with obstinate constipation has been 
described. According to O'Beirne it is the uppermost part 
of the rectum that is usually the seat of the stricture. It is 
exceedingly rare and occurs as a partial enterospasm in hys- 
terical and neurasthenic states, or under the influence of certain 
pathological conditions. 

4. Spasmodic or Irritable Sphincter (without Fis- 
sure). — This is much more frequent than the same condition 
in the rectum; it is a partial enterospasm occurring also in 
hysteria and neurasthenia. It may depend upon an enlarged 
prostatic gland or an inflammatory condition of the prostate. 
In females it may be present in chronic conditions of the 
genital organs. It is attended with irritability of the bladder. 

Imperfect Performance of Physiological Function. — Atony 
of the Intestine, Causes, and their Mode of Action. — 
By far the greatest number of cases of constipation that come 
under our observation are due to imperfect performance of 
physiological function, more particularly of the large bowel. 
Atony not only implies the loss of muscular force but also a 
loss of normal irritability. As a result of this atony and con- 
sequent diminution of its irritability the large bowel is unable 
to expel its residual matter properly and constipation results. 



CONSTIPATION 63 

Judging by analogy from what we see in the salivary gland, it 
may be assumed that this loss of muscular power may also 
result in a diminution in the action of the muciparous glands, 
lessen the amount of mucus secreted and thus retard the 
passage of the fecal matter, causing it to be dry and hard. 
The causes that lead to such impairment are : 

i. Neglect. — Neglect to attend to the calls of nature recur- 
ring daily for a considerable time results in the establishment 
of a toleration on the part of the mucous membrane and the 
terminal afferent nerve filaments, and thus the bowel becomes 
habituated to the presence of extraneous matters which should 
have been discharged as soon as they reached the rectum in 
any quantity. 

2. Reading at Stool. — By this pernicious habit the inhib- 
iting influence of the will is directed from the spinal centre 
controlling the sphincter; the latter remains in its normal 
state of contraction, and thus the fecal matter is not extruded. 
The controlling influence of the mind over the functions of the 
rectum is well illustrated by what frequently happens to us 
all, namely, when nature calls us to evacuate the bowel some 
work or subject of great interest will arise to divert us, when 
almost immediately the desire ceases. 

3. Food Defective in Residual Matter. — A certain amount 
of residual matter, such as coarse vegetable fibre, is not only 
necessary for the excitation of the peristalsis of the large 
bowel, but also prevents the fecal matter from packing in hard 
masses by the readiness with which it absorbs and retains the 
fluids. This is a very important fact to be borne in mind in 
the treatment of chronic constipation, especially now that 
our foodstuffs have been so refined by the improved machinery 
of the present day. This factor as the cause in the production 
of constipation has been very much enhanced by the present 
custom, so common, of living upon prepared concentrated 
foods. As an offset to this custom, fruit should be eaten with 
their skins, when edible, as apples, peaches, plums, etc. Our 
flour and meal should not be so thoroughly bolted, and we 



64 DISEASES OF ANUS, RECTUM, AND SIGMOID 

should eat more freely of vegetables that contain a large pro- 
portion of coarse fibrous tissue, such as cabbage, cauliflower, 
turnips, etc. By following these rules, our food not being so 
concentrated we will have to eat a larger quantity in order to 
obtain the requisite amount of nourishment. 

Food Deficient in Fats. — A very important fact that should 
constantly be borne in mind is that fats are not indigestible in 
proper proportions to persons whose digestion is normal, and 
that they are very important constituents of the fecal matter, 
tending to keep it soft. 

4. Abstaining from Cold Water. — This habit is frequently 
formed through ignorance of the good effect of cold in stimu- 
lating the circulation, the nerve filaments, and the muscular 
coats of the stomach and intestines. Warm solutions, on the 
contrary, produce turgidity of the circulation of the intes- 
tinal tract, obtund the normal sensibility of its nerve filaments, 
and relax its muscular tissues. Added to these objections 
the warm solutions habitually taken are decoctions containing 
astringent and other deleterious properties, such as tea and 
coffee. 

5. Want of Sufficient Physical Exercise. — Exercise is 
known to stimulate all the physiological processes going on 
within the organism, few if any less so than the functions of 
the rectum and sigmoid. The circulation is hastened, the 
respiration is accelerated, the destructive metamorphosis of the 
tissues becomes more rapid, the appetite is increased, and the 
muscular structures are invigorated. Few appreciate the bene- 
fits to be derived from exercise in obviating or overcoming 
constipation. We have seen cases entirely relieved by this 
measure alone. 

6. Muscular Weakness of the Abdominal Walls. — This is 
generally due to the neglect of proper measures after parturi- 
tion, or more rarely to some defect of muscular development. 
The pendulous belly is not only the cause of constipation but 
produces a form of it that is most difficult to overcome. 



CONSTIPATION 65 

J. Obesity. 

8. Prolonged Mental Work; Prolonged Mental Worry; 
General Depressing Influences. 

9. Bad Teeth or Want of Teeth. — This results in imper- 
fect mastication and dyspepsia. 

10. Old Age. — The general debility incident to old age, the 
torpidity of the secreting organs, and the inability to exercise 
are frequent causes. 

11. Warm Water by Injections and the Habit of Taking 
Purgative Medicine. — The prolonged use of warm injections 
causes turgescence of the parts, relaxes the action of the 
muscles, and dulls the normal irritability of the nerves. The 
relaxation of the muscles is also brought about by the over- 
distention due to the quantity of warm water generally neces- 
sary to accomplish the desired results. 

12. Incidental Causes. — Inadvertent constipation is caused 
by certain derivatives of the mineral kingdom which tend to 
dry up the secretions of the bowel and harden the faeces 
(Birch, " Constipated Bowel," 1868). These substances are 
alum, the salts of lime, the salts of lead, iron, and copper, which 
are taken in our food as adulterants, coloring matter in candies, 
and copper in pickles. 

Symptoms. — The usual symptoms of constipation are so 
familiar as not to need any very careful enumeration, yet there 
are some unusual cases which are not known to the average 
physician. 

Usual Symptoms. — The tongue is coated, there is offensive 
breath, headache, loss of appetite, irritability of temper, hebe- 
tude, general feeling of malaise, and moroseness. 

Local Symptoms. — Distention, heaviness in the belly, flatu- 
lency, rumbling noises in the bowels, pain in the sides or back 
under the liver or the inferior angle of the left scapula, some- 
times itching at the anus ; the faeces are hard and dry. 

Unusual Symptoms. — Unusual symptoms are vertigo and 
a hypochondriacal condition. Illoway reports a case of pro- 

5 



66 DISEASES OF ANUS, RECTUM, AND SIGMOID 

found stupor, which lasted three weeks, owing to prolonged 
constipation due to an anal fissure. 

Etiology of the Symptoms. — Senator holds that the 
symptoms are due to intoxication by sulphuretted hydrogen 
gas. This is denied by most authorities. Rosenheim contends 
they are caused by augmented putrefaction in the albuminoids. 
This view presents many obstacles. Illoway's opinion is that 
they are based upon the disturbances of the nervous, circula- 
tory, and glandular systems of the intestinal tract, due to the 
pressure exerted by the hardened masses. Constipation may 
also interfere with the diffusion of C0 2 , and its consequent 
accumulation in the blood may contribute to the production of 
the perturbations. 

Diagnosis. — As a rule the diagnosis is easily made from 
the statement of the patient and the history of the case. These, 
however, cannot always be relied upon. Many times while 
the patient may have had daily evacuations they have been 
insufficient, and a large portion of the fecal matter that should 
have come away is left behind to become harder and drier. 
At other times (this is a very deceptive condition), the patient 
may have frequent watery stools which may even be involun- 
tary, with tenesmus and bearing down. If this is accompanied 
with a history of previous constipation, the case may almost 
be diagnosed by the symptoms, but it is always best to make a 
digital examination, which will readily confirm the condition. 

One of the chief points in the diagnosis of constipation is 
to establish at the outset, if possible, whether it is an idiopathic 
condition or due to one of the many indirect pathological 
processes already alluded to in the first part of this chapter. 

In addition to the digital examination of the rectum as a 
means for diagnosing constipation, auscultation over the 
descending colon and sigmoid can also be used with great 
advantage. In the digital examination of the rectum, besides 
being able to ascertain the existence of scybalous masses, the 
examiner should feel for a stricture, polypi, obstructions by 
displacement of enlarged adjoining organs and other growths, 



CONSTIPATION 67 

and should look for the presence of a fissure or hemorrhoids 
as active causes in the production of constipation. 

If the digital examination fails to indicate a satisfactory 
cause, let the rectum be washed out by an enema and the 
pneumatic proctoscope used for a high examination, including 
the sigmoid. The same obstructions should be looked for high 
up as already enumerated in making the low examination. 
In addition the condition of Houston's valves should be care- 
fully inspected, to ascertain what, if any, obstruction they may 
offer to the passage of the faeces. As an additional aid to the 
diagnosis of obstructions high up in the bowel, resort may be 
had to the careful inflation of the bowel by carbonic acid gas 
or ordinary air pumped into the bowel by means of a double 
bulb, with a nozzle attached to the end of its tubing. With 
the bowel inflated we may, by percussion, easily locate foreign 
bodies, tumors, indurations, and strictures high up. 

In making the proctoscopic examination of the rectum, all 
local pathological conditions likely to produce constipation, 
such as chronic catarrh, atony accompanied by relaxation of 
the intestinal walls, etc., should be noted. 

Prognosis. — " It is not at all a question as to life." Life 
is not endangered by constipation, with few exceptions, as in 
ileus paralyticus, and Illoway relates a case of death from 
asthenia which followed apparent recovery from prolonged 
and obstinate constipation. Recovery as a rule is favorable, 
even in those cases in which there is dilatation or even hyper- 
trophy of the bowel when properly managed. The excep- 
tions to the rule are : I. Where there is a marked and pro- 
longed dislocation of the bowel ; II. Where the abdominal 
walls are very flabby and relaxed; III. In old people where 
there is not only atony but degeneration, the existence of any 
of these makes the prognosis unfavorable. 

The Consequence of Constipation. — The three prominent 
and constant functional disorders that always result from con- 
stipation are an inhibition of peristalsis, an accumulation and 
hardening of faeces, and an obstruction to the circulation of 



68 DISEASES OF ANUS, RECTUM, AND SIGMOID 

the rectum and sigmoid which results in turgescence and 
congestion. 

Among the pathological conditions resulting from con- 
stipation may be mentioned hemorrhoids, anal fissure, typhlitis, 
due to the distention of the caecum by fecal matter, and its 
consequences; a certain number of cases of appendicitis, as in 
a large percentage of such cases fecal concretions are found 
in the appendix; membranous enteritis, sigmoiditis, prostatitis, 
enteroliths, dilatation, which may be general, involving the 
whole of the large bowel from the caecum to the anus, or 
limited, affecting any section thereof ; ulceration, diverticulitis, 
hernia, as a result of violent straining at stool to overcome 
constipation ; diarrhoea with constipation and intestinal obstruc- 
tion, auto-intoxication. While this has generally been ac- 
credited as one of the results of constipation, Illoway opposes 
the idea for the very good reasons that the symptoms, such as 
headache, anorexia, and the insomnia of the constipated, which 
are supposed by some to be due to intoxication, are too 
promptly relieved by a thorough purgation for this to be the 
cause, and also from the fact that in cases where there have 
been large accumulations of faeces for a long time the symp- 
toms of auto-intoxication do not exist, which they should do 
in a marked degree if resulting from constipation. Illoway 
in further proof of this assertion quotes Bouchard, who says : 
" The objection often raised to the hypothesis of auto-intoxica- 
tion of fecal origin is the fact that constipation is compatible 
with good health. If the hypothesis were true, auto-intoxica- 
tion should be realized in its highest degree in the constipated. 
I answer that constipation must be regarded as a protection 
against auto-intoxication. It presumes that all that can be 
absorbed has been absorbed." There is, however, danger of 
intoxication when we have a diarrhoea established with the 
constipation, because the fluid fecal matter, which in this 
instance comes from the small intestine, is not discharged 
rapidly enough on account of the accumulation of hardened 
faeces in the large bowel. 



CONSTIPATION 69 

Treatment. — I consider first treatment of the idiopathic 
form of constipation, the most common form of which is 
due to : 

Atony of the Intestinal Musculature . — 
The two necessary requirements for consideration are : I. 
Removal of the cause ; II. Restoration of the muscular tone. 

First Requirement. — Removal can generally be accom- 
plished by a scrupulous regularity in responding to the calls 
of nature and a punctilious observance of a fixed time for 
going to the toilet, whether the inclination exists or not. In 
the event of failure, after reaching the toilet, it should be 
induced by the action of some local stimulant, the best of 
which is a cold-water enema. 

Diet. — The effect of diet in preventing or overcoming 
constipation cannot be too strongly urged, nor do we think 
the part it plays is half appreciated by either professionals or 
laity. When it is remembered that fully nine-tenths of the 
fecal discharges are made up of the indigestible constituents, 
the excess of those that are digestible, and the offal of our 
food, it will be readily seen from the recent great advances 
in the preparation of food that there is little of the indigestible 
or offal left, so that by these refinements of civilization con- 
stipation is induced, both by the concentration and the refined 
character of the food. In order to prevent the nitrogenous 
portion of our food from packing or from forming hard and 
scybalous masses, which it is inclined to do, it should be taken 
in connection with a large amount of vegetables and fruit 
which contain a considerable amount of cellulose, this being 
almost entirely indigestible in the intestinal tract of man, 
except to a limited extent by the micro-organisms which it 
meets with in the large intestine and which are capable of 
breaking up cellulose to a limited extent. Consequently this 
constituent furnishes a liberal amount of indigestible material 
which separates the nitrogenous waste matters, acts as a sponge 
to retain the water, and furnishes a mechanical irritant for 
stimulating- the afferent nerves of the intestinal mucosa. 



70 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Therefore our food should consist of a liberal amount of coarse 
vegetables, fruits with their peels, properly prepared, cereals, 
and breadstuffs with their husks. 

Drink. — The effect of fluids in preventing or overcoming 
constipation is as great as that of diet. The great importance 
of fluid to the animal economy is well recognized, and its 
mechanical effect in keeping the fecal matter moist and soft 
can be readily conjectured. The chief question in this con- 
nection is in what condition (cold or warm) is it best taken? 
It is well known that cold water stimulates intestinal peri- 
stalsis and gives tone to its musculature, while warm water 
relaxes its musculature and blunts its sensibilities. Therefore 
for the purpose of overcoming constipation water should be 
taken cold, and in order to keep the fecal matter moist it 
should be taken in large quantities, best when the stomach is" 
empty so as not to interfere with digestion by diluting the 
digestive fluids. 

Exercise. — This also has an important bearing in the regu- 
lation of this function. A long brisk walk, a ride on a bicycle 
or 'on horseback, either of which should be sufficiently active 
to stimulate the circulation and produce free action of the skin, 
are the best means of taking it. When unable to get it in 
either of these forms, calisthenic exercises or " The Whitely 
Pulley Method " may be substituted, and should be taken on 
a porch or in a cool, well-ventilated room. 

Second Requirement. — The restoration of the muscular 
tone can best be done in the majority of cases by mechanical 
methods, although a tonic, with gently stimulating therapy, 
must not be entirely ignored, especially in early treatment when 
every possible means will be necessary to restore the function 
even to a partial performance of its duty. These measures 
may be divided into mechanical and therapeutic means. 

Mechanical. — I. Massage; II. Hydrotherapy; III. Elec- 
tricity. 

Massage. — This has been found of the greatest benefit in 
the treatment of habitual constipation, and is best adapted to 



CONSTIPATION 71 

those cases of prostration and extreme weakness in which the 
patients are unable to take a regular amount of active exercise ; 
but do not let it ever take the place of active exercise except 
under these conditions. Hazzard, in a paper read before the 
American Proctologic Society, at Atlantic City, June, 1909, 
spoke of that form of constipation which resists and defies 
laxatives, purgation, corrected diet or special diet, walking, 
horseback riding-, or any form of gymnastics. There are cer- 
tainly many such instances. All of the mentioned remedies 
are useful, although only palliative, failing to completely empty 
the tube, and directly the patient ceases to follow the regimen 
suggested, which he will soon do, he relapses into the same 
condition as before. Hence the necessity for a better method, 
which is, in my opinion, abdominal massage. 

There are five generally accepted movements in massage : 
Friction, rolling, compression, kneading, and percussion. In 
treating the abdominal organs, including the nerves, lymph- 
spaces, juice canals, vessels of all kinds, as well as the accu- 
mulations which may be there, any (or better all) of these 
movements should be combined, although friction and per- 
cussion are of doubtful utility. The main points which would 
seem to deserve the most consideration are : Firmness com- 
bined with gentleness, persistence, the slow breaking up and 
displacement of any retained faeces wherever found, and the 
compression of every gland concerned with digestion and 
assimilation. A few points which I have learned through 
experience are these : 

First, to clear out the rectum by enemata if anything be in 
it, as no amount of massage affects the rectum except it be 
done in the fossa, and this does not amount to much. 

Second, to always begin with the descending colon and as 
much of the sigmoid as may be reached (bearing in mind pos- 
sible malformation and redundancies of the sigmoid) ; then 
at subsequent visits taking the other parts in the order of their 
anatomical position. A poor way to evacuate a sausage is to 
begin pushing upon its contents at the proximal end. A vast 



72 DISEASES OF ANUS, RECTUM, AND SIGMOID 

amount of damage may result from general massage of the 
abdomen at the beginning of the treatment. Lakes of lique- 
fied faeces may be and will be created which cannot rind exit 
and are only rendered the more absorbable. I have seen 
headache, high temperature, and severe muscular pains result 
from non-observance of this rule. 

The third point is, to use gentleness at the first treatment. 
The patient always has some soreness following the first few 
treatments, and is very apt to discontinue the matter altogether 
if the masseur is too rough. More vigorous movements may 
be resorted to after confidence is gained. The first few treat- 
ments should upon no account be delegated to another, not 
even to a trained nurse, as unskilled manoeuvres are most apt 
to prove worthless or, what is worse, harmful. If the first 
manipulations are not done by the surgeon, personally, they 
had best be left off altogether. Some of the contraindications 
for its use are atheroma and aneurisms. 

Massage acts by stimulating the circulation and the lym- 
phatic vessels, by the absorption of effete products, and by 
improving the general muscular tone. 

Hydrotherapy. — Under the head of hydrotherapy for the 
relief of constipation due to atony may be mentioned the fol- 
lowing measures : 

Clysters, Cold Tub Baths, Cold Com- 
presses, Co 1 d Moist Friction . — Of these various 
measures I speak here at length only of the following : 

Clysters . — As rectal injections are so generally used 
for habitual constipation, I mention abuses of the method and 
give the proper directions for their application. 

What has been said previously of the effects of cold and 
warm water, when taken by mouth on the intestinal tract is 
applicable when administered by enema and has the same effect 
on the general muscular tone and peristalsis of the rectum. 
The warm water relaxes the muscular coats of the rectum and 
obtunds the sensory nerve endings, consequently the use of 
warm-water enemas can only act temporarily by overdistention 



CONSTIPATION 73 

of the rectal walls, which leaves them in a more relaxed con- 
dition and in turn increases the constipation. The practice of 
flushing out the bowel with large quantities of warm water, 
so generally recommended by quacks in order to advertise 
their fountain syringes, is therefore most pernicious. 

On the other hand, the use of cold-water enemas is a most 
useful and satisfactory method of stimulating rectal peristalsis 
and making the rectum do its own work. This may be done 
frequently, only as a reserve force, to stimulate the rectum at 
the appointed time when other means may have failed, and 
leaves the bowel each time that it is used in a better condition 
by its general tonic effect and by having made the bowel per- 
form its own function. The small quantity of water necessary 
for this purpose does not distend the bowel unduly and im- 
proves its muscular tone. There need be no fear of any dele- 
terious effect to the adjoining organs from the cold water 
used, except possibly during menstruation. The fountain 
syringe is the most convenient instrument. 

Position . — Where it is only necessary to use a small 
quantity of cold water for the purpose of stimulating the bowel 
to action the horizontal position will answer the purpose, but 
in cases where constipation has continued for several days, 
and you wish to stimulate both rectum and sigmoid to action, 
then it is very important for the patient to be placed in the knee- 
chest position, or if too feeble to assume such a position, the 
same results to a less degree may be obtained by placing him 
in the left lateral position, with a pillow under the hips to 
elevate them above the shoulders and head. In either of these 
positions, with a short nozzle, a high enema can be given under 
all conditions, even though the impaction may be extensive, 
as by elevating the bag of the syringe sufficient pressure may 
be obtained to distend the bowel enough to allow the water to 
pass around and above the obstruction. 

Cold Compresses and Cold Moist Fric- 
tions . — Both may be used very satisfactorily, by stimulating 
the bowel reflexly to do its own work. 



74 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Electricity. — That the rectum may be stimulated to activity 
by an electrical current is generally conceded, and the con- 
tinued and frequent use of it may overcome permanently the 
constipation due to atony has been confidently affirmed by 
Dr. Dwight Murray in his article on "A Rational Treatment 
of Chronic Constipation " (New York Medical Journal, Nov. 
3, 1906), and others. Murray's technic for the use of this 
remedy is as follows : 

" The patient is placed in the Sims position, an electrode, 
after the pattern of Ewald with a perforated soft-rubber shield, 
is passed into the sigmoid. The rectal electrode is connected 
from its binding post to the positive pole of the battery, 
and rubber tubing connects it also with an irrigator, filled with 
normal saline solution, which is elevated about three and a half 
feet above the patient. The rapidity of the flow of normal 
saline is controlled by a stop-cock in the electrode. The nega- 
tive electrode is made of sheet lead, large enough to cover the 
abdomen, and is well padded with a towel wrung out of hot 
normal saline solution. The electric saline douche washes all 
fecal debris and mucus from the intestinal mucosa, leaving a 
clean surface for medication, which is of the utmost impor- 
tance in the treatment. It enables us to apply medicinal agents 
to the mucous surfaces without the interposition of the almost 
impermeable coating which the secretion constitutes. 

" The effect on the mucous membrane, and on the intestinal 
and the abdominal muscles, of the galvanic current applied in 
this manner seems to be soothing and quieting to the chronic 
inflammation. The relief of the inflamed condition leaves the 
muscles free to act, lessening what may be termed muscular 
fear. My patients tell me that they have better power of 
expulsion than before the treatment was begun. The normal 
saline solution in the irrigator is kept at no° F., and is turned 
on just before the electric current is started. The amount of 
electricity used varies from five to twenty-five milliamperes, 
according to different physical conditions. 



CONSTIPATION 75 

" When the first part of the treatment is finished the 
abdominal skin is well reddened, and feels as though a mustard 
plaster had been applied. No electricity reaches the tissues, 
except as the connection is made by the normal saline solution 
slowly running through the electrode into the sigmoid flexure. 
This makes an electrode of all parts of the colon which the 
solution reaches, without discomfort to or danger of burning 
the patient. This part of the treatment occupies from ten to 
twelve minutes, and from thirty-two to sixty-four ounces of 
normal saline solution is thrown into the sigmoid and descend- 
ing colon. The patient is then allowed to go to the toilet, 
where a free evacuation takes place, leaving the intestinal 
mucosa clean. 

" He then returns to the table for the last half of the treat- 
ment. This consists in throwing one ounce of an emulsion of 
olive oil, i pint ; iodoform, i drachm ; bismuth subnitrate, 2 
ounces (as advised by J. M. Mathews for disease of the sig- 
moid), into the descending colon through a Wales bougie or 
a special tube which I have devised. This is followed by one 
or two ounces of some dilute astringent or antiseptic solution 
or hydrastis. The iodoform is omitted from the emulsion if 
the patient has an idiosyncrasy that would make its use inad- 
visable, but I find they do better when using it. After throw- 
ing the medicament into the sigmoid, the patient is kept for 
about ten minutes on the table, so tipped that the hips are 
elevated considerably, allowing the emulsion to gravitate high 
up in the colon. The treatment is given every fourth day until 
patients have daily normal stools without help, after which the 
time between treatments is lengthened until the patients are 
wholly on their own resources. The successful practise of 
this method involves the expenditure of much time, each treat- 
ment occupying approximately one hour. 

" When this treatment is begun, patients are ordered to 
stop the use of all laxatives. They are instructed to go to 
the toilet at a regular hour each day and make an honest effort 
to stool, taking fifteen or twenty minutes, if necessary, using 



76 DISEASES OF ANUS, RECTUM, AND SIGMOID 

gentle pressure, but never to strain. Failing in this, the use 
of an enema of plain water, or normal saline, is directed in 
order that the bowel may be educated to empty itself at a 
regular time. While under this treatment patients are allowed 
liberal diet. Excess of pastry, confections, and condiments is 
prohibited, and they are directed to drink at least six glasses 
of water daily. 

" As to results of my method, I find that daily stools follow 
the first treatment in many cases, others after only a few 
treatments. Comparatively few cases are unsuccessful in 
obtaining a daily stool, and even these show manifest improve- 
ment in their general condition. My records show that 75 
per cent, of the cases are cured, while nearly all of the other 
25 per cent, are improved. Although each patient is asked to 
give a year to the treatment, only one has thus far taken treat- 
ments for so long a time. 

" It would tax your patience to go into detail by the report 
of cases. Some have been little short of miraculous in results 
obtained. Four and a half years is the oldest cured case I 
have, a time-test sufficiently long to prove the value of what 
seems to me rational treatment of chronic colitis, which is the 
real pathological condition in chronic constipation. 

" Some explanation of my reason for employing the treat- 
ment may be of interest. The oil soothes and lubricates, iodo- 
form acts as an alterative and antiseptic, while bismuth has 
a healing effect on all diseased and ulcerated surfaces. These 
are applied directly to the surface of the mucous membrane. 
Astringent and other solutions used to follow the emulsion 
have their effect locally, according to the kind used and the 
effect desired." 

Therapeutic Treatment. — The use of laxative medicines 
is nearly always called for, for the immediate relief of both 
acute and chronic constipation, and also to supplement and 
assist other forms of treatment. These should be mild in 
character, such as preparations of cascara sagrada and senna, 
in moderate doses, to be omitted as soon as possible. 



CONSTIPATION 77 

Operative Treatment. — It should be a rule, to be always 
borne in mind, in the treatment of constipation, to remove all 
decided obstructions to the passage of fecal matter, whenever 
practicable. This would include hemorrhoids, polypi, narrow- 
ing of the lumen by stricture, and the division of Houston's 
valves, when they offer sufficient resistance to the passage of 
fecal matter to obstruct its exit. 

The first three of these obstructions will be considered 
under their respective headings. As the latter is only done 
for the relief of the obstructive form of constipation and this 
is the proper place for its consideration. 

Thomas Charles Martin, of Washington, D. C, was the 
first to suggest this operation (valvotomy) for the relief of 
obstipation. The need for the operation in a given case of 
constipation is ascertained by testing the resistance of the 
valve by a blunt hook. Whereas they offer little or no resist- 
ance to being drawn down by the blunt hook in their normal 
condition, the resistance is considerable when the valve is 
infiltrated with fibrous tissue, as a result of chronic interstitial 
inflammation. His technic for the operation is as follows : 
The bowel should first be thoroughly evacuated and then irri- 
gated with antiseptic solution. The patient is placed in the 
knee-chest position, and a tubular speculum of 30 mm. diameter 
is introduced up to the projecting valve (Fig. 27). The valve 
to be divided is then fixed by two long hook-shaped tenacula, 
which are made to transfix the valve from above, to the right 
and left of its centre, the space between them being where 
the incision is to be made. The depth to which the valve 
should be divided is determined by the point at which a uterine 
sound, curved to three-quarters of a circle, is arrested when 
introduced above the valve and pulled downward. The dis- 
tance between this and the free border of the valve is the depth 
to which the incision should be made. The knife, the tenacula, 
and the hook all have long handles ; the knives have two varie- 
ties of blades, one a curved, sharp-pointed bistoury, the other 
a scalpel. They have all been devised by Martin and are 



78 DISEASES OF ANUS, RECTUM, AND SIGMOID 

shown in Fig*. 28. The transfixion should be made when the 
valve is at right angles to the intestinal wall, and not when it 
is drawn down. To avoid pulling the valve down in this pro- 
cedure, Martin advises the use of proctoscopes of different 
lengths, so that they will just reach and bolster up the valve. 




Fig. 27. — Testing resistance of valve with Martin's hook. (From Hemmeter's Dis. of the 
Intestines.) 



The first incision, which is very shallow, is made with the 
curved sharp-pointed bistoury, and this incision is carried to 
the required depth by the scalpel. If much hemorrhage results, 
he advises suturing the cut edges of the mucous membrane 
together, for which he has devised some ingenious instruments 



CONSTIPATION 



79 



for introducing the sutures. His subsequent treatment con- 
sists in the daily inspection of the divided valves, with such 
local treatment to them as may suggest itself to the operator. 
J. Rawson Pennington, of Chicago, Illinois, says : " After 
having one case of peritonitis and another in which there was 
a severe hemorrhage following the operation as above de- 
scribed, I devised a clip and an instrument for applying the 




Fig. 28. — Martin's over and under valvotomy scalpels. But one knife is necessary if it be 
provided with a reversible handle. (From Hemmeter's Dis. of the Intestines.) 





Fig. 29. — Pennington's clip for cutting rectal valves and the instrument for 
applying it. (Tuttle.) 

same (Fig. 29) to the valve, which severs or cuts out an 
elliptical piece from the free border of the valve by pressure 
necrosis. The clip and instrument are passed into the rectum 
through a tubular speculum (Fig. 30). This method of 
cutting through the valve is not attended with hemorrhage or 
the risk of peritonitis, while it accomplishes similar results to 
the cutting operation devised by Martin. Both Martin and 
Pennington, as well as others, report a number of cases of 
constipation that have been absolutely cured by these methods. 



80 



DISEASES OF ANUS, RECTUM, AND SIGMOID 



Jerome M. Lynch has recently devised a long-stemmed angio- 
tribe (Fig. 31) with which to take V-shaped pieces out of 
the valve. The author thinks it is far preferable to the clip, 
as one or more pieces can be taken out of the same valve or 
several valves at the same sitting without any risk of hemor- 
rhage or any other bad results. 

I do not doubt the efficacy of such methods of treatment, 
provided the constipation is due to obstruction by the too- 




FlG. 30. — Pennington's clip applied. (Tuttle.) 



resistant valves; but I am, however, of opinion that such cause 
of constipation is not nearly so frequent as has been supposed. 

The treatment of those cases of constipation due to indi- 
rect causes should be considered in connection with the primary 
disease. 

Impaction. — Cases of fecal impaction, where there are 
large, hard and dry scybalous masses, often attended with an 
oozing of fluid fecal matter, due to irritation set up in the rectal 
walls by the hard masses, produces oedema of the parts, and 



CONSTIPATION 81 

results in excessive secretion of a thin watery mucus, which 
dissolves a small amount of fecal matter from the surface of 
the scybalous masses and accounts for the fluid stools. Very 
misleading and suggestive of diarrhoea, it should always sug- 
gest a digital examination, which will immediately reveal the 
true condition. It is always best to break up scybalous masses 
immediately, as far as possible with the finger, which is better 
than any instrument, being far less liable to injure the bowel. 
Let this be followed first by an injection of from one to two 
ounces of hydrogen peroxide, which has the property of dis- 
solving the fecal masses very promptly — a suggestion first 




Lynch's electric angiotribe. 



offered, we believe, by A. B. Cooke, of Nashville, Tennessee. 
Repeat this every three or four hours, until all the fecal masses 
are dissolved, which can only be known by a digital examina- 
tion. If the peroxide of hydrogen does not excite sufficient 
irritation to cause the bowel to expel its contents, then a large 
enema of warm soapsuds, with cotton-seed oil, may be admin- 
istered in the knee-chest position. 

To insure complete emptying of the colon and even of the 
caecum, nearly always loaded in these cases, castor oil in one- 
ounce doses, or compound licorice powder in two dram doses, 
should be given every four hours, until several large and soft 
evacuations are brought away. 

In obstinate cases of constipation where not any of the 
above causes exist to account for the constipation, and where 
the constitutional symptoms from the absorption of effete 



82 DISEASES OF ANUS, RECTUM, AND SIGMOID 

products are sufficient to warrant it, an abdominal section 
should be made in order to ascertain the length of the sigmoid 
and its meson, with its probable bearing on the constipation. 

The abnormally long sigmoid (together with the acute 
angulation that results from it) has been generally recognized 
in recent years by writers as a very important and frequent 
factor in the production of constipation. For the correction 
of this defect there have been several remedies suggested. 
The first, which was the most rational, was to straighten the 
sigmoid and fix it by attaching it to the abdominal parietes ; 
this is known as sigmoidopexy, the technic for the perform- 
ance of which is described under the treatment for third degree 
of prolapse of the rectum. An objection to this method has 
been pointed out by J. G. Clark, of the University of Pennsyl- 
vania, on the ground that " it is a wrong principle to attach 
a movable organ, where it can be avoided," and he suggests 
as a substitute " lateral anastomosis between the two extremes 
of the sigmoid loop at the point where they most nearly 
approximate each other (Fig. 32) in cases where the 
redundancy of the sigmoid is not sufficient to justify resection 
(as in Chapter XXI on Congenital Idiopathic Dilatation of 
the Colon, Hirschsprung's Disease), and is producing very 
exaggerated constipation." 

While lateral anastomosis is the more difficult operation to 
perform, yet it meets the abnormal conditions more 
effectually with the least violence to the normal condition of 
motility in the sigmoid. Clark supports this suggestion by the 
report of a case in which a very aggravated form of constipa- 
tion, attended with profound toxic symptoms, was permanently 
relieved by such a procedure. 

Psychotherapy. — The treatment of constipation would 
be incomplete without some reference to the very satisfactory 
results obtained from psychotherapy by Irving Phillips Lyon 
of Buffalo, N. Y., Curtis F. Burnam of Baltimore, and others. 
Here I quote at length from a paper read by Dr. Lyon before 
the Congress of American Physicians, Transactions of the 



CONSTIPATION 83 

American Physicians, 1908. He is of the opinion that many 
of the contribtitary causes of constipation are merely secondary 
to the neglect of training the bowels to functional regularity, 
and says further (I quote verbatim) : 

" The Final Cause of Habit Constipation is Habit. — This 








Fig. 32. — J. G. Clarke's lateral anastomosis. 



habit involves both the mentality and the special nerves of 
function of the intestine. The latter are encouraged in their 
loss of control or of spontaneous action indirectly by the 
mental habit of conviction of necessary local disturbance in 
the intestines. So long as the mind of the patient continues to 



84 DISEASES OF ANUS, RECTUM, AND SIGMOID 

be misinformed as to the real cause of the functional disturb- 
ance, tinkering with the minor agents of relief is likely to 
prove ineffectual in inducing a radical cure, although such a 
cure may occasionally be induced by any method of treatment 
that includes strong suggestive authority by the physician and 
systematic fixing of a regular time for the act of defecation.. 
Such cures only prove the rule of causation herein urged. This 
view of causation, if correct, suggests naturally the proper 
method of treatment. 

" Method of Treatment. — Psychotherapy, Training in 
Habit, and Accessory Stimuli. — In treating habit constipation, 
the force of habit must be recognized and combated. All 
habits have a certain mental equivalent or representation. 
The habit of constipation is no exception. In a sense it seems 
to be a functional disturbance related to a psychoneurosis, a 
psychoneurosis of function. However obscure and ill-defined 
the mental representation may appear in theory, in practice, at 
any rate, it becomes evident. 

" If, in practice, a strong vigorous man of fifty-two applies 
to a physician for the relief of chronic constipation that has 
persisted from earliest childhood without interruption, without 
once in fifty years permitting natural spontaneous defecation 
without cathartics, and if this man is so far influenced in his 
mentality regarding his fixed habit of constipation by a single 
interview with the physician, without drugs, without change 
of diet, without any chemical or physical agents whatever, but 
merely by conversation, so as to be cured over-night and there- 
after permanently through the next year, is there any doubt 
that the constipation has a representation in the mind of the 
patient, is, in fact, a pure psychoneurosis of function? If 
somewhat similar experiences are repeated many times, not 
only in men in robust health, but also in bed-ridden neuras- 
thenic women, cured permanently by conversation alone and 
promptly over-night or in the course of a few days, can one 
deny in such instances the existence of a psychological equiva- 
lent of constipation? Such experiences have occurred repeat- 



CONSTIPATION 85 

edly in my practice, exactly as represented in the hypothetical 
cases. I cannot doubt, then, the existence of some kind of 
mental influence over the function of the bowels. The exact 
nature of this influence may be an interesting subject for 
speculation and investigation, but here may not be considered. 
The useful application of the fact alone interests us here in 
the object of treatment. Psychotherapy is clearly indicated. 

" Such a mess of puerile nonsense has lately been exploited 
with the public under the designation of psychotherapy that 
the very term now tends to arouse suspicion, distrust, and 
even disgust in the scientific medical profession. This is but 
natural for a conservative body, but cannot be justified. If 
psychotherapy has been debased and exploited by ' new- 
thoughters ' of every breed, it has also been cultivated and 
developed by scientific investigators and raised to a legitimate 
use. For its proper use no apology is needed. 

" How then is psychotherapy to be applied? What are its 
limitations? What other factors can be combined with it to 
advantage, and how important are such other factors or acces- 
sory stimuli? It must be frankly admitted that these are ques- 
tions not easy to answer in the space of a readable paper. 
Only the briefest outlines can be given in reply, and personal 
experience alone can satisfy. One might as well give rules to 
convert a heathen as to explain how to talk with a man who 
has constipation into a conviction and realization of its ready 
cure. The subtlety of psychology cannot be mastered by rules 
on paper. I can attempt, therefore, only to give the principles 
involved and a crude outline of the general average method of 
procedure. Variations to suit the individual must be suggested 
by the circumstances of each case. One person needs sympa- 
thetic persuasion, another logical exposition, another must be 
taken by storm and forced into submission. . 

" The sine qua non of success, I believe, is the evident 
sincerity of conviction of the physician arousing the hope and 
faith of his patient. The instinct of sincerity and confidence is 
felt by contact, and cannot be aroused by a lukewarm doubter. 



86 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Before trying this method of treatment, some degree of enthu- 
siasm must be aroused in the physician himself by a knowledge 
of psychology and some general reading of the best works 
expounding its practice in therapy. If confidence in the method 
can be felt, enthusiasm and experience can be trusted to work 
out the details for successful practice.. It was along such 
lines and by such procedure that I developed my own experi- 
ence, still immature, but growing. 

" I will not weary you with the details of conversation 
necessary to overcome the opposition of the patient and to 
secure not only his blind faith in the authority of his doctor, 
but also his logical persuasion. It would be impossible to 
reproduce the many arguments that were found expedient to 
convince the various types of patients. It should be empha- 
sized, however, that the means of persuasion need not often 
include back-handed, indirect, and subtle suggestion, but only 
straightforward, simple, sincere, heart-to-heart conversation. 
Explanation of the way the mind operates in making and 
unmaking habit, unequivocal assertion that the psychological 
method meets few failures, is almost sure and certain, bolster- 
ing the wavering hope of the patient by reading the records of 
success in other patients, burning all bridges behind to prevent 
retreat by persuading the patient to actually destroy his drugs, 
these are the simple arguments that win the faith of the 
patient. 

" When once his faith and confidence are enlisted, the 
rest is easy. A single fixed time for a daily movement of the 
bowels must be chosen and all efforts concentrated to produce 
regularity of action at this time, i.e., habit. In fixing the time 
for the movement, some consideration should be paid to the 
patient's convenience and duties. Furthermore, inquiry should 
be made as to whether there is any tendency whatever for nat- 
ural defecation to occur at any special time. If so, advantage 
should be taken of this tendency, slight and irregular though 
it be, and this time should be the one chosen for the regular 
movement. In the great majority of patients the most natural 



CONSTIPATION 87 

and convenient time is a few minutes after breakfast, and unless 
strong reasons for selecting another time are presented this 
should be chosen. The patient should go to stool at the exact 
appointed time, whether or not any inclination to defecate is 
felt in advance. While at stool he should concentrate his 
attention upon his object, should avoid premature straining, 
and should not coax his bowels too long in case spontaneous 
action does not soon occur, waiting at the most ten minutes. 
If success is not obtained within this time, postponement of 
further effort should be made to the next day at the same 
hour. 

" If strong inclination should be felt later in the day it 
should be resisted, and the bowels should be told, like a spoiled 
child, as it were, that they must move at one time and at that 
time only. In many cases, at the beginning, as the habit of 
constipation begins to yield, a difficulty is encountered in the 
occurrence of an urgent demand for defecation at other times 
than the appointed morning hour. The patient must be 
instructed to resist such inclination, however urgent, until the 
control of regular morning action has been thoroughly mas- 
tered. Subsequently', however, it will be found practicable and 
desirable in some cases to encourage the habitual action of 
the bowels a second time in the day, best at night. 

" In case of complete failure for three days in succession, 
the large intestine should be emptied by means of a large 
enema and the patient encouraged to persist in his efforts. 
It is well not to suggest in advance the possibility of failure 
by directing the use of an enema after three days of failure, 
but rather to instruct the patient to report his success to the 
physician on the second day, when, if necessary, the enema 
may be ordered. As a rule, it will not be required. If there 
has been a partial success, the patient should be encouraged to 
persist and to expect greater success on the following days. 
When, during the first few days of trial, the bowels fail to 
move for three days in succession, the enema which is ordered 
should be taken immediately after the expiration of the ten- 



88 DISEASES OF ANUS, RECTUM, AND SIGMOID 

minute period of effort for natural action, thereby causing a 
movement approximately at the regular time, thus helping to 
fix this time in the habit which it is sought to establish. 

" Certain natural stimuli as accessories may be used to 
advantage at the start in helping to establish regularity. The 
most important of these are regularity in the general daily 
habits, going to bed at a fixed hour, rising at a fixed hour, 
taking a morning cold sponge bath, sipping a glass of water 
while dressing, taking breakfast at a fixed hour, and eating an 
abundant coarse diet including a variety of vegetables, fruit, 
brown bread, and similar articles. Plenty of water should also 
be taken. Precise directions covering all such details should 
be given because of their importance as accessory stimuli and 
also for the psychological effect of painstaking directions upon 
the patient. After success has been obtained and regularity 
long established, the patient need pay little or no further atten- 
tion to the accessory stimuli. He will lead a normal life and 
will not return to his former habits. If he should chance to 
lapse on a single day now and then, it will give him no concern, 
he will not think of taking a dose of physic, but will confidently 
await success on the next day at the appointed hour. His 
mentality regarding constipation is completely changed. He 
can even take a dose of physic on special occasions without the 
slightest fear of interrupting his established habit of regularity. 
In short, when once cured he remains cured because he has 
established a fixed habit of control of function. 

" Many physicians claim, when the outline of this treatment 
is presented, that it represents nothing new, is similar to what 
they have practiced, and that they have always sought to 
establish regularity of function at a specified time. Whether 
it is new is unimportant, that it is effective with only rare 
exceptions establishes its claim to some degree of distinction 
from the methods commonly practiced. This distinction lies 
chiefly in its emphasis on psychological influence. The thor- 
oughness and persistence with which such influence is exerted 
determine its success. A full hour or more is required for 



CONSTIPATION 89 

the first interview with the patient, and thereafter frequent 
and regular reports by him should be insisted upon to enforce 
the principle and to meet possible difficulties. Half-hearted 
trial and routine, lacking individualization, fail. Enthusiasm, 
thoroughness, and persistence succeed. 

" It is not claimed that psychotherapy exclusively in all 
cases is sufficient. Often it is. But faulty habits in the mode 
of living must be corrected. If a man eats too little, or food 
that is too fine, rich, and concentrated, he must be given a diet 
that is sufficiently abundant, bulky, and coarse. If he leads a 
sedentary life, without sufficient exercise to maintain a healthy 
constitution, he should be encouraged to correct this fault, 
and appropriate and congenial recreation and exercise should 
be discovered and prescribed. If the patient is nervous, thin, 
and tired, increased rest must be insisted on and forced feeding 
instituted. How frequently are such patients made worse in 
all their symptoms by excessive exercise, such as horseback 
riding, bicycling, hard walking and climbing, prescribed by 
physicians ? I have seen the case of a constipated, dyspeptic, 
reduced neurasthenic stock breeder, whose occupation had 
kept him in the saddle daily for years, apply for relief to a 
great hospital, and be directed to get out of bed, go out on 
the street and walk, in order to get fresh air, exercise, and 
strength ! 

" Even drugs may be employed, if clearly indicated, to 
combat special conditions and complications. Constipation in 
a girl with chlorosis cannot be cured permanently until the 
chlorosis is cured by iron. The constipation dependent upon 
diseases of the heart requires perhaps a course of digitalis. 
Such clear indications for drugs need not be denied or avoided. 
Their proper use in no wise compromises the principle of 
rational psychotherapy. Constipation secondary to organic 
diseases is, however, not included in the subject of this paper, 
which, as is implied throughout, concerns only or primarily 
functional habit constipation. In this condition drugs should 
be used with caution and cathartics not at all, in my judgment. 



90 DISEASES OF ANUS, RECTUM, AND SIGMOID 

In the series of cases here presented cathartics or laxative 
drugs were not once used. Few drugs of any kind were ever 
employed, and when they were their identity and purpose were 
frankly stated to the patient. In a few instances a few doses 
of sodium bicarbonate and bismuth or belladonna were admin- 
istered to relieve gastric pain. Bromides were sometimes used 
at the beginning in cases of general nervousness with con- 
stipation. In several cases of malnutrition in constipated 
neurasthenics, nux vomica was pushed vigorously. Broadly 
speaking, nux vomica as a general tonic to the nervous system 
and to appetite and digestion was the only drug that played 
any appreciable part in the treatment of the cases as a whole. 
When it was prescribed care was taken to inform the patient 
that it was not a cathartic, but merely a general tonic, thereby 
maintaining consistency and authority with the patient in 
winning moral control. 

" Statistics and Observations. — Final Results. — Cases 
treated, 69; cured, 68; failure, 1. These 69 cases were all 
cases of habit constipation of long standing, varying from a 
few months to fifty years or more. The only complete failure 
was in the case of an educated woman, aged forty years, a 
most obstinate neurasthenic, who gave the impression of 
caring more for her complaints and the sympathy they aroused 
than for their cure. The cause for this failure may, however, 
be related to the possible effects of several attacks of peritonitis 
which had occurred about twenty years before from pus tubes. 

" Time Required for Cure. — This varied from one day to 
four weeks ; the majority of cases were cured within two 
weeks, several in a single day. The case requiring four weeks 
proved about two months subsequently to have inoperable 
cancer of the rectum; in spite of this the cure remained com- 
plete until an operation of colostomy was performed three 
months after the cure. Some of the cases of longest duration 
and greatest obstinacy were cured on the first day, as, for 
instance, a strong man, aged fifty-two years, leading an out- 
of-door life, who stated that he had never within his recollec- 



CONSTIPATION 91 

tion from earliest childhood had a single movement of the 
bowels except as a result of cathartics. His complete and 
permanent cure was established the next morning after a single 
interview, more than a year ago. During this period his 
bowels moved regularly and sufficiently every morning except 
for an interruption of two days following an automobile acci- 
dent. Similar one-day cures, while the exceptions have not 
been rare, and include a wide range of types of patients, strong 
men apparently without nerves and weak nervous women, 
two of the latter bed-ridden neurasthenics with many serious 
symptoms in addition to constipation. 

"Permanency of the Cure; Relapses. — So far as I know, 
not a single case in the sixty-eight reported as cured has per- 
manently relapsed into the previous condition, though such a 
possibility cannot be denied, as several of the cases disap- 
peared. So far as I have been informed, in only a few 
instances has a partial relapse occurred and then only tem- 
porarily." 



CHAPTER IV 

SIMPLE CATARRHAL PROCTITIS; SIGMOIDITIS; 
MEMBRANOUS COLITIS 

The structure of the mucous membrane of the rectum and 
sigmoid with their myriads of Lieberkuhn follicles, together 
with the fact that these are the resting-place for fecal matter 
for so long a time, makes them peculiarly susceptible to this 
form of inflammation. Under this heading are included only 
the simple catarrhs, i.e., such inflammations of the mucous 
membrane as are not due to any specific germ yet recognized. 
The specific catarrhs, on account of the fact that they almost 
invariably terminate in ulceration, will have separate considera- 
tion under Specific Ulceration. 

The similarity of the glandular element of the rectum and 
sigmoid, and even of the colon, together with their functional 
resemblance, makes it very improbable that this form of 
inflammation should be confined to any one of them for any 
length of time, although there are cases where the inflamma- 
tion may be confined to one of these localities. Simple catarrh 
may be either acute or chronic; the latter subdivided into 
atrophic, hypertrophic, and membranous catarrhal colitis. 

Acute Catarrhal Proctitis. — Etiology. — This may be 
induced by sudden changes of temperature ; irritating or stim- 
ulating food ; very frequently by the lowering of the local 
temperature as by sitting on cold marble; injection of irritating 
substances into the rectum ; and by impacted faeces and foreign 
bodies. There is almost unquestionably a predisposition on 
the part of certain individuals to catarrhal inflammations in 
general, and of the rectum and colon especially. I have said 
advisedly that simple inflammations may be induced by these 
causes, implying only that the vitality of the parts is thereby 
lowered, thus allowing non-specific organisms to get in their 
work. 



SIMPLE CATARRHAL PROCTITIS 93 

Symptoms. — The attack may be ushered in by a slight 
chill, general aching pains especially about the sacrum and 
around the pelvis, with slight elevation of temperature, and a 
sense of weight, heat, and burning in the rectum. If the dis- 
ease is high up there will be more discomfort in the lower 
abdomen, but tenesmus, bearing down, and a desire to go to 
stool will be very marked. This is also likely to be attended 
with the frequent desire to micturate. The stools are fre- 
quently soft, or even fluid, mixed with mucus and often with 
small flakes of blood. If the inclination is severe and persists 
for several days it may terminate in ulceration and even in 
sloughing of the mucous membrane. Should such a result 
follow, the discharge from the rectum will become muco- 
purulent or sanguinopurulent. In children the frequent con- 
tinued straining is likely to bring on prolapse of the mucous 
membrane. 

On palpation the parts feel hot, dry, and very sensitive in 
the first stages ; subsequently, moist and slimy, from the 
excessive secretion of mucus. Through the speculum the 
mucous membrane is bright red in color and (edematous ; sub- 
sequently, the color is a darker red. The inflammation is 
generally confined to the mucous membrane ; it may extend to 
the submucosa, seldom to the muscular wall. 

Dr. Dwight H. Murray, Syracuse, New York, has reported 
to me a case (which I quote) of pigmentation of rectal mucous 
membrane, which was evidently a condition due to acute proc- 
titis : " Proctoscopic examination shows a dark brown almost 
blackish color of the mucous membrane from the anus upward, 
as far as can be seen. It is also studded with small yellowish 
spots, pencil-point in size, some larger, having the appearance 
of tissue undergoing fatty degeneration. The mucous mem- 
brane bleeds rather freely." 

Treatment. — In mild cases the inflammation will generally 
subside under rest and repeated irrigations of the rectum with 
warm water containing some mild antiseptic ; this is best 
done by a rectal irrigator (Fig. 33). The one here pre- 



94 DISEASES OF ANUS, RECTUM, AND SIGMOID 

sented is, I believe, the best. It was devised by A. L. Wol- 
barst, and shown at the meeting of the American Urological 
Association, Atlantic City, New Jersey, June, 1909. Dr. 
Wolbarst believes it to obviate the objectionable features of 
the Kemp and Chetwood tubes, which are in general use. 

The tip of the instrument is of soft, pliable rubber, which 
gives easily on contact with the rectal wall, and the flow of 
fluid into the rectum is through a number of small openings, 
thus providing a fountain spray instead of a single or double 
jet. 

The apparatus consists of two tubes, a small one inside a 
larger. The water enters through the small tube (Fig. 34a) 
and fills up the soft rubber pouch (Fig. 34b) which is per- 




Fig. 33. — Wolbast's improved rectal irrigating tube. 

forated with numerous pin-head openings, through which the 
fluid enters the rectum. Escape from the rectum is only pos- 
sible through the large opening (Fig. 34c) in the larger tube. 
The external sphincter prevents any outflow at the anus. 

The instrument is made of nickle-plated brass tubing, with 
a soft-rubber tip; its total length seven inches, including the 
rubber tip. The diameter is equivalent to 38 of the French 
scale. The soft rubber projects i}4 inches beyond the end of 
the large tube; it is slipped over the bulbous end of a short 
metal tube, the distal end of which is provided with a male 
thread, which is screwed into the end of the large tube (Fig. 
34e) and thus securely wedged in place; also can unscrew 
the rubber tip and thoroughly clean it and the metal tubes 
at w T ill. 



SIMPLE CATARRHAL PROCTITIS 95 

In all cases, however, the entire large bowel should be thor- 
oughly evacuated by a large dose of castor oil. Great relief 
may be obtained by the application of a hot-water bag to the 
perinaeum. The diet should be devoid of much refuse or irri- 
tating material, and should consist of concentrated proteids, 
such as eggs, broths, and finely-minced meats, which are 
digested principally in the stomach and contain a minimum 
amount of refuse ; also the simple starchy foods, such as rice 
and tapioca, with a moderate amount of sugar. Milk is to 
be prohibited, except in very moderate quantities with the 
starches, on account of the hard scybalous masses that are 
formed from it. 



*/ 




Fig. 34. — Wolbast's improved rectal irrigating tube. 



Should the inflammation proceed to the ulcerative stage, in 
addition to irrigation with warm antiseptic solutions, local 
applications maybe made through a proctoscope once in twenty- 
four hours, or 1 to 2 per cent, solution of nitrate of silver, or 
a 15 to 20 per cent, solution of argyrol. Either of these may 
be applied with a cotton swab or, better, in a spray. Should 
the rectum be too sensitive for the introduction of a procto- 
scope, these solutions may be injected into the rectum with a 
small hard-rubber syringe, in quantities from one to two 
ounces, with the hips well elevated. 

The patient should be confined to bed until pus and blood 
have disappeared from the stools and until after the sense of 
weight and bearing down have passed away. The restricted 
diet should, however, be continued for at least several days 
longer. 



96 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Medicines by the mouth are seldom needed in these cases, 
except opium in some mild form to allay the straining and dis- 
comfort about the rectum ; even this is better with starch water 
in the form of an injection. Subnitrate of bismuth in 20- 
grain doses with salol in 5-grain doses may be given with some 
advantage to lessen the irritating character of the discharges 
and to control excessive fermentation. 

Chronic Proctitis. — There are two types of chronic catar- 
rhal inflammation of the rectum, the hypertrophic and 
atrophic ; if the acute form should become chronic it generally 
assumes the hypertrophic type. 

Hypertrophic Catarrh. — This must not be confounded 
with proliferating rectitis, which is a syphilitic inflammation. 

Pathological Changes. — In this form of inflammation both 
the mucous membrane and submucosa are always thickened, 
the glandular elements much hypertrophied, the intertubular 
substance considerably increased, in conjunction with the con- 
nective tissue of the submucosa : it may extend up into the 
sigmoid. In simple hyertrophic catarrh the bacteria found 
in the scrapings from the surface of the bowel show only such 
organisms as are found in the normal intestinal tract. It may 
follow the acute type, or may result from the same causes, 
acting in a more gradual and milder way. 

Symptoms. — If it succeeds an acute catarrh the acute 
symptoms may nearly subside with a gradual development of 
the chronic ones, otherwise they are vague and indefinite in 
the early stages. There is flatulency, tenesmus, loss of appetite, 
and general malaise ; diarrhoea frequently alternates with con- 
stipation, although the latter is the usual condition and may 
be attended with a frequent desire to defecate, which results 
only in the passage of a small quantity of mucus; the stools 
containing a considerable quantity and, sometimes, mucopus. 

The above symptoms, especially disorder of the diges- 
tive system, and constipation become more marked as the 
disease progresses. The patient loses strength, becomes more 
nervous and anxious about his condition, and there is frequent 



SIMPLE CATARRHAL PROCTITIS 97 

exhaustion following the stools. Pruritus is a frequent symp- 
tom, most commonly due to oozing of mucus through the 
sphincter. For the same reason the radial folds become hyper- 
trophied and frequently the papillae around the anal margin 
become so hypertrophied as to form typical condylomata. The 
most satisfactory method for confirming the diagnosis is 
through the speculum, which shows the mucous membrane of 
the rectum to be cedematous, thickened, pale, and covered with 
a thin whitish secretion. When the mucus is wiped off the 
mucous membrane presents a somewhat granular appearance. 

Treatment. — The treatment is likely to be prolonged and 
tedious, and the results from local treatment being uncertain ; 
it is well to be cautious in giving a prognosis, as it may be 
necessary to operate in order to effect a cure, though, before 
resorting to such a procedure, it would be proper to exhaust 
all therapeutic measures likely to 1 produce the desired result. 

As in acute catarrh, the first thing is a thorough clearance 
of the large bowel, this being best effected by castor oil. After 
this, the bowel shoud be well flushed with a warm solution of 
antiseptic powder N. F. i to one pint, with the patient in a 
knee-chest position and the solution passed in very slowly. 

Diet. — A restricted one, as prescribed in the acute form, 
containing fresh lean meats, eggs, sugar, and such starches as 
contain the minimum amount of residual matter is best, taking 
care in the use of the latter variety of foodstuffs to restrict 
them in quantity and character in order to limit the acid fer- 
mentation to which they are liable to give rise. White potatoes, 
for this reason, should be positively prohibited ; rice and corn- 
starch being substituted, and certain tender green vegetables 
allowed, as spinach and asparagus-tips. Let milk be taken 
only in very small quantities ; coffee and tea have no bad 
effect in the majority of cases, but alcohol in all forms should 
be proscribed. 

Medicinal Treatment. — The bowels should be kept free 
from fecal matter, and this is usually accomplished by the 
antiseptic douches; but the water that comes away should be 
7 



98 DISEASES OF ANUS, RECTUM, AND SIGMOID 

examined to see that it contains the requisite amount of fecal 
matter, and, when it does not, administer a gentle laxative, 
such as moderate doses of cascara. 

The excessive intestinal fermentation to which .these 
patients are so prone may in a measure be controlled by the 
use of aspirin in from five- to ten-grain doses, given three 
hour's after meals and preferably in capsule form. Local appli- 
cations directly to the diseased bowel should be made daily or 
on alternate clays, either following the antiseptic douch or an 
irrigation by plain sterile water. These applications should 
be made through a proctoscope, better in the form of a spray 
or applied by the means of a cotton swab. They should consist 
of a 20 to 30 per cent, solution of argyrol, or a 30 per cent, 
solution of ichthyol, or an application of an emulsion made 
with the following proportions : 

Iodoform : 1 dram ; 

Bismuth subnitrate 2 ounces ; 

Olive oil ... 1 pint 

(Dr. J. M. Mathews) ; or a 1 to 2 per cent, solution of nitrate 
of silver. If, after being used for a reasonable length of time 
(from two to three months), these measures fail to relieve, 
then resort may be had to surgical measures, appendicostomy, 
hereafter to be described, its rationality lying in the proba- 
bility that most, if not all, of the large bowel is involved in 
the catarrhal condition, and the only efficient means of meet- 
ing it consists in being able to irrigate the large bowel from 
the caecum down. 

Atrophic Catarrh. — This form of catarrhal inflammation 
is said to be common, but such has not been my experience. 
It is not generally found until the age of puberty, but occurs in 
increasing frequency with the advance of age. It is generally 
confined to the rectum and sigmoid. 

Pathology. — Upon examination the mucous membrane is 
found to be dry, rough and inelastic, presenting a peculiar 
appearance upon inspection. The surface seems laid off in 



SIMPLE CATARRHAL PROCTITIS 99 

irregular squares with lines separating- one from the other, 
the surface within each square seems slightly raised above 
the intervening lines. Taken collectively, it much resembles 
small block tiling, an appearance peculiar, I believe, to this 
form of inflammation, and so far as I know to be taken as one 
of the surest diagnostic signs. In addition there is frequently 
found, attached to the surface here and there, small masses of 
dry fecal material, and occasionally small pieces of necrotic 
epithelium, the microscopic examination frequently confirming 
this by showing the epithelium absent in many places. 

The glands of Lieberkuhn are frequently atrophied, the 
intertubular tissue decreased, the goblet-cells diminished in 
number. Quenu and Hamonic affirm that in these cases the 
cylindrical epithelium is changed to the stratified pavement 
type. The tile-like appearance of the surface, previously 
described, would seem to indicate such a change in the epithe- 
lium, although the authors just quoted affirm such change not 
to extend more than one or two- centimetres above the anal 
line and to be confined to the surface, not involving the tubules. 
The connective tissue of .the submucous coat is dense and 
slightly thickened. 

Etiology. — Dr. James P. Tuttle has observed atrophic 
catarrh to be so frequently associated with obscure syphilitic 
disease that there must be some dependence of the former 
upon the latter. With this exception, there does not appear to 
be any one very definite etiological factor to account for this 
trouble, though I do find it, however, following high living, 
close confinement with hard work in badly-ventilated rooms, 
and eating improper and insufficient food. It may also result 
from the practise of sodomy, the use of irritating enemata, 
and from foreign bodies in the rectum, and it may follow 
chronic inflammation of the pelvic and genito-urinary organs, 
by vascular or lymphatic extension. 

Symptoms. — There is nearly always a history of a long 
continued constipation, with dry and hard stools, which are 
more or less coated with mucus; these stools are frequently 



100 DISEASES OF ANUS, RECTUM, AND SIGMOID 

followed with severe pain and heat and burning in the rectum, 
with some degree of spasm of the sphincters. The stretching 
of the anal folds produces cracks or minute fissures in the 
mucocutaneous tissues, with, nearly always, marked dilatation 
of the rectal ampulla. The mucous membrane of the entire 
rectum may be eroded and deeply ulcerated in spots, probably 
due to the traumatism produced by the passage of the dry 
and hardened faeces over an improperly lubricated mucous 
membrane and its subsequent infection. There is likely to be 
indigestion and flatulency, with other concomitant symptoms 
of the former and, very probably, as in hypertrophic catarrh, 
some pruritus ani. 

Treatment. — This form of catarrh being practically limited 
to the rectum and lower sigmoid, can be best treated locally. 
Keep the surfaces free from irritating fecal matter by irriga- 
tions, these serving as an antiseptic, and stimulating applica- 
tions to the mucous surfaces. These irrigations may be made 
to serve the purpose of hastening the absorption of inflam- 
matory products by stimulating the circulation with hot water 
which is allowed to flow through a rectal irrigator, for fifteen 
to twenty minutes at a sitting. As an antiseptic the pulv. anti- 
septicus N. F. i dram to i pt. and other mild antiseptics may 
be used. Should these irrigations fail to thoroughly empty 
the rectum and sigmoid of fecal matter, then recourse may be 
had to gentle laxatives, such as fluid extract of cascara, in 
15 to 20 drop doses. 

While the diet needs to be regulated, so as to exclude 
irritating substances, it need not be so* rigidly exclusive as in 
hypertrophic catarrh. 

Local Applications. — These should be made daily through 
the proctoscope, carried up to the sigmoid, after the bowel has 
been thoroughly washed out with the antiseptic solution. 
These local applications may be more stimulating than in 
hypertrophic catarrh, as for instance with a 5 per cent, solution 
of nitrate of silver, a 30 per cent, solution of argyrol, etc., all 
better applied by spray. 



SIGMOIDITIS 101 

If the atrophic catarrh is complicated by the existence of 
hemorrhoids, which is frequently the case, these should be 
removed by the usual methods, but it is better to wait until 
the inflammatory condition has in a large measure subsided. 

Fistula and extensive ulcerations, which are also frequent 
complications in atrophic catarrh, may be treated in the usual 
manner, except that it would not be prudent under these con- 
ditions to close up the fistulous tracts immediately. 

Sigmoiditis. — The sigmoid is peculiarly susceptible to both 
the milder and more aggravated forms of catarrhal inflamma- 
tion, the latter even involving all the coats of the bowel (as 
will be shown hereafter), on account of its being the special 
abiding place for the retained fecal matter. Considerable 
light has recently been thrown on this condition in its more 
aggravated form, sigmoiditis. 

Sigmoiditis may be divided into the simple and the infec- 
tious. I only deal here with the former, the latter being con- 
sidered in connection with the specific ulcerations of the 
rectum, as dysenteric, tubercular, etc. Simple sigmoiditis may 
in turn be divided into catarrhal, ulcerative, and interstitial. 
The simple catarrhal form may be either acute or chronic, and 
is nearly always due to a previous constipation, with a sigmoid 
overloaded with hard, dry, fecal masses, which produce ero- 
sions of its epithelial surface and stasis in its circulation. It 
may, however, be an extension from an attack of proctitis, or 
a part of a general enteritis. 

Symptoms. — Constipation very pronounced, flatulence, 
loss of appetite, griping pain, frequent desire to defecate, with 
passages of hard lumpy fecal matter, or sometimes by watery 
stools, as in impaction of the rectum; these are attended with 
mucus, and sometimes with blood. These symptoms may all 
subside in a short time, following a thorough evacuation of 
the bowels, to recur with another attack of constipation. It 
is these recurrences that give rise to the ulcerative, and the 
latter to the interstitial form of the disease, both of which 
are attended by the same symptoms, in an aggravated form, 



102 DISEASES OF ANUS, RECTUM, AND SIGMOID 

except that in the ulcerative there is a decided increase in the 
amount of blood and mucus passed, also an increase of pain; 
and in the interstitial form there is decided tenderness in the 
left iliac region, simulating closely a left-sided appendicitis, 
with dulness on percussion and induration; both of these 
latter varieties are likely to be attended with elevation of 
temperature. 

The interstitial variety, which is merely an extension of 
the inflammatory condition to all the coats of the sigmoid, 
including its peritoneal coat, is that form which gives rise to 
the classical diverticulitis and perisigmoiditis which has recently 
attracted so much attention among various writers. 

While perisigmoiditis may be occasioned by an extension 
of inflammation from adjoining organs, the large majority 
of cases reported have been primarily due to a weakening of 
the sigmoid wall by inflammation, then to the formation of 
diverticula. The latter, which may also be congenital 
(although Telling, writing on its etiology, says it is significant 
that no case in a child has so far been recorded), becomes 
filled with fecal matter, gradually resulting in a leak into 
the mesosigmoid or into subperitoneal tissues, giving rise to 
inflammation and frequently to suppuration. It is in this 
latter condition that the walls of the bowel and its meson 
become so thickened and indurated as to be mistaken for 
malignant growths. George Emerson Brewer, Mayo, and 
Byron Robinson were the first to call attention to the true 
character of this condition, and its differentiation from malig- 
nant growths in this locality. Thos. S. Cullen reports a 
similar condition, Diverticula of the Rectum (American Med. 
Assn. Journal, Nov. i, 1904). (Fig. 35.) 

Digital examination of the rectum reveals little except 
the presence of the thickened tissues above, and this only by 
counterpressure over the left inguinal region. By the procto- 
scope little can be seen, except in the acute and ulcerative 
stages, when the inflamed or ulcerated mucous surfaces will 



SIGMOIDITIS 



103 



present the same appearances as those described under the 
head of Simple and Ulcerative Proctitis. 

The ulceration of the mucous surfaces may be present in 
the interstitial stage, but of course nothing further than the 
ulceration could be appreciated through the proctoscope. This 
condition can be best estimated and diagnosed by touch and 
palpation through the abdominal walls. Both Byron Robinson 




Fig. 35. — Tumor of the sigmoid flexure due to rupture of diverticula into the surround- 
ing adipose tissue. Small pelvic abscess. 

and J. Rawson Pennington have called attention to the influ- 
ence of an overloaded sigmoid from constipation as a factor 
in pelvic diseases. 

Treatment. — Simple ulcerative and interstitial sigmoiditis, 
when not complicated with diverticula require the same treat- 
ment as that for similar stages of proctitis — namely, keeping 
the bowel free from accumulations of fecal matter, and using 



104 DISEASES OF ANUS, RECTUM, AND SIGMOID 

antiseptic irrigations in the knee-chest position. When the 
interstitial stage is complicated by diverticula, perisigmoiditis, 
or mesosigmoiditis, or if the latter conditions should be the 
result of a leakage of fecal matter from a congenital diver- 
ticulum, surgical interference must be resorted to. The clin- 
ical evidences of diverticulitis are in the form of inflammatory 
trouble, more or less acute, in the left lower abdomen, left- 
sided tumor, and abscess formation, intestinal obstruction, 
perforative peritonitis, or vesicocolic fistula. 

As Telling has pointed out, " inflammatory trouble of the 
above kind in a patient of middle age, or older, one who had 
been the subject of marked or former constipation, might at 
best render a diagnosis of diverticulitis very uncertain and it 
would be much safer to label such a case sigmoiditis, one of 
the commonest causes of constipation." 

Differential Diagnosis. — He also says (London Lancet, 
March 28, 1908) : " The chief conditions to be considered in 
differential diagnosis would appear to be (a) ordinary appen- 
dicitis with left-sided symptoms; (b) pelvic inflammations; 
(c) ovarian cysts with strangulation, or inflammation; (d) 
actinomycosis of the sigmoid flexure; and (e) syphilitic and 
tuberculous pericolitis. This list does not exhaust the pos- 
sible sources of error; diagnoses of pancreatic, ovarian, and 
csecal tumors have been made." 

George Emerson Brewer (Journal of The American Med- 
ical Association, August 15, 1908) says that from his experi- 
ence " acute diverticulitis, like appendicitis, may be divided 
into four clinical groups: Group 1, in which there is a mild 
inflammation of a diverticulum, which subsides like a catar- 
rhal appendicitis under rest and appropriate medication. 
Group 2, with inflammation more severe and progressive, in 
which the diagnosis is made and an operation performed 
before rupture takes place. As the opening connecting a 
given diverticulum with the intestine may be small, the acute 
inflammatory process may serve to completely occlude it, and 
empyema of the diverticulum, with or without the presence of 



SIGMOIDITIS 105 

a concretion, may develop. Group 3 would comprise those 
cases in which there has been a rupture of the diverticulum, 
with the formation of a localized intraperitoneal abscess, or 
if the diverticulum is situated in a portion of the intestine 
not covered by the peritoneum, the entire process may be 
without the peritoneal cavity. The history of the first attack 
of the patient reported would correspond with this type of 
the disease. Group 4 would include all cases in which rupture 
of the inflamed diverticulum into the free peritoneal cavity 
had taken place, with a resulting spreading and generalized 
peritonitis. 

" The symptoms and signs of acute diverticulitis are prac- 
tically identical with those of acute appendicitis in its various 
forms, the only difference being that the former occurs as a 
rule on the left side of the abdomen, rather than on the right. 

" Sufficient data are not available to enable determination 
as to the percentage of inflamed diverticula that actually per- 
forate, it is therefore not possible to state dogmatically whether 
a given case of acute diverticulitis, with comparatively mild 
symptoms, should be subjected to immediate operation, or be 
treated more conservatively. In my opinion, however, the 
clinical course of the disease is so similar to the various forms 
of acute appendicitis, that the treatment should be the same. 
Certainly in all acute cases, with severe and progressive symp- 
toms, safety lies in early operation. 

" Regarding the operative technic of the treatment of 
inflamed, or gangrenous, diverticula, my experience has been 
far too limited to lay down any hard and fast rules, but I 
am of opinion, however, that if the diverticulum is small, or 
attached to the bowel by a narrow pedicle, removal with clos- 
ure of the intestinal wound by a purse-string, or several 
Lembert sutures, should be done, provided the surrounding 
intestinal wall was not too much infiltrated. In the event of 
the diverticulum being large, attached by a broad base, or 
covered by a plexus of enlarged vessels, the safest method 
would be the one employed in the case reported, that is, by 



106 DISEASES OF ANUS, RECTUM, AND SIGMOID 

extraperitoneal drainage. If the situation of the lesion is 
such that extraperitoneal treatment cannot be carried out, I 
suggest packing with gauze from the abdominal wound to 
the lesion, leaving this packing in place from forty-eight to 
seventy-two hours, or until firm adhesions have formed about 
the gauze ; then removal of the gauze and free opening of the 
abscess, and allowing it to drain through the channel thus 
formed. 

"If rupture has already occurred, the intestinal wound 
should be united by suture, if this be possible ; if not, adequate 
drainage should be provided." 

Membranous Colitis. — Although the colon above the sig- 
moid is not regarded as belonging to the field of the rectal 
surgeon, yet abnormal conditions of discharges from the 
rectum are now so generally regarded as due to some local 
functional, or pathological, lesions that they are generally 
referred to the rectal specialist for diagnosis and treatment. 
This is particularly true of membranous colitis, a form of 
the disease to be considered under this heading. 

Colitis may be divided into simple and specific, the former 
only to be here considered under three aspects, acute, chronic, 
and membranous; the latter may be a stage of either of the 
former. It is generally believed that there are many cases of 
an aggravated form in which neither inflammation of the 
colon, nor any other of the local pathological conditions, 
hereafter to be described as exciting causes, can be found. 
These are considered to be purely neurotic in origin, but it 
may be safely said, that if a careful search is made in all 
cases, one of the pathological lesions will be found as an 
exciting cause. 

Etiology. — While the causes that produce acute and 
chronic forms are similar to those of hypertrophic and trophic 
proctitis, the consideration and treatment of which answers 
for that of colitis, there are additional causes active in the 
production of the membranous variety. 



MEMBRANOUS COLITIS 107 

Kaabak and Rosenschein give as the result of their research, 
the fact that mucus is produced in excessive amounts only at 
the point where there is local irritation. They found it impos- 
sible to induce production of excessive amounts of mucus by 
applying irritation at other points. Their findings are con- 
firmatory of others in this line and emphasize the necessity 
for assuming circumscribed local irritation as the cause of 
increased production of mucus in any stretch of the intestines, 
or in the stomach. 

A. B. Cooke (Transactions American Proctologic Society, 
1909, page 91), in an article on " Diseases of the Colon Due 
to Extra-intestinal Causes with Special Reference to Mem- 
branous Colitis," says : " Personally I have never seen a 
case of chronic colitis of any type in which I failed to find 
unmistakable evidences of a pathological lesion in the mucosa, 
though I have seen cases in which it was impossible to dem- 
onstrate the presence of pathological conditions of other 
viscera. 

" With reference to this type of colitis I am prepared to 
state unequivocally that I have never seen a case in which 
I failed to find some gross pathological condition of one or 
more abdominal organs as well as the mucosa itself; and 
furthermore that the etiological relation between the two 
has been clearly established in a number of cases by the prompt 
and permanent disappearance of the bowel trouble upon the 
correction of the extra-intestinal conditions after all other 
methods of treatment had failed." 

The most generally recognized causes giving rise to mem- 
branous colitis are the following : 

(a) Inflammatory adhesions to the pelvic organs or walls. 
" Pathological fixation of any portion of the colon, even 
though only partial, is necessarily attended by retardation of 
peristalsis, with the result that the bowel is exposed to in- 
creased traumatism from within as well as from without. In 
this way inflammation of the mucosa is induced and mucous 
and membranous colitis, which are merely advanced stages of 



108 DISEASES OF ANUS, RECTUM, AND SIGMOID 

the inflammatory process, follow. The sites at which these 
adhesions are most frequently encountered are the caecal 
region, the gall-bladder region, and the sigmoid loop of the 
colon by extension of the inflammatory process from the pelvic 
organs." — A. B. Cooke. 

(b) Regarding subacute inflammation of the vermiform 
appendix, when not a part of a general colitis, Howard A. 
Kelly in his work on " Appendicitis and Diseases of the 
Vermiform Appendix" says: The association of mem- 
branous colitis and chronic appendicitis is frequently observed. 
Finney has especially noted its occurrence in cases where there 
is a thickened, chronically inflamed appendix, densely adher- 
ent to the neighboring intestines. Some writers have attrib- 
uted the disease of the appendix to the influence of the chronic 
colitis, but the evidence as a whole favors an appendiceal 
origin, the affection of the colon being secondary. In many 
instances acute attacks of appendicitis have antedated the 
appearance of symptoms of colitis, and it is a common expe- 
rience to find that the latter is entirely relieved by the removal 
of the appendix. Lapeyre (Zeit. f. Chir., 1903, page 498) 
described six cases in which coincident appendicitis and muco- 
membranous colitis were cured by removal of the appendix. 

The relation of mucous colitis and appendicitis is very 
interesting. As I have said elsewhere, obstipation and colitis 
with mucous stools are often the signs of a latent appendicitis, 
and are cured by the removal of the appendix. The differen- 
tial diagnosis, as a rule, rests upon the history of mental strain 
or worry preceding the onset of the trouble and the presence 
of marked nervous manifestations, such as hysteria, hypo- 
chondriasis, etc. On the other hand, a history of a preceding 
acute or chronic appendicitis is exceedingly suggestive of the 
appendiceal source of the trouble. In any case of mucous 
colitis in which nervous symptoms are not a predominant 
feature of the disease, appendicitis should be suspected. 

Tuttle in a paper on " Mucous, Mucomembranous, and 
Membranous Colitis " (Nezc York Medical Journal, Vol. 85, 



MEMBRANOUS COLITIS 109 

1907, page 823) has recorded twenty-two such cases asso- 
ciated with chronic appendicitis, nineteen of which were en- 
tirely relieved by an operation for appendicitis; the three fail- 
ures prove rather than refute the dependence of membranous 
colitis upon peritoneal adhesions, as in each of the three there 
were extensive adhesions involving- more or less the entire 
caput coli, and although broken up they reformed as shown 
by subsequent laparotomies. 

(c) It may be associated with malignant diseases of the 
bowel, for in sixty cases of membranous colitis reported by 
Dr. W. Hale White, three of them were so associated in the 
large intestine. 

(d) It may be due to a floating kidney. In five of the 
cases reported by White and four by Tuttle there were floating 
kidneys on the right side, all the cases being relieved by restor- 
ing and anchoring the kidney in its normal position. A. B. 
Cooke says : Normally, the upper extremity of the posterior 
surface of the ascending colon is in direct contact with the 
anterior surface of the right kidney. When, from any cause, 
the kidney becomes loosened from its bed the only direction in 
which it can move is downward and the same intimate rela- 
tion is capable of being maintained throughout the whole 
length of this portion of the colon. It is further to be noticed 
that in the great majority of instances (70 to 80 per cent.) 
the posterior surface of the ascending colon, like the kidney, is 
retroperitoneal, being connected directly to the abdominal wall 
by areolar tissue, and that the pathway of a pathologically 
mobile kidney lies in immediate relation with this unprotected 
surface. With these anatomic facts in mind and remembering 
that the amount of the kidney's motion is, to a considerable 
extent, determined by respiratory action, it is not so remark- 
able that the mechanical irritation incident to its oft-repeated 
round-trip excursion over the same route should ultimately 
result in an inflammation of the colon. 

(e) It may be due to enteroptosis. Cooke says of the 
association between these two that membranous colitis, in 



110 DISEASES OF ANUS, RECTUM, AND SIGMOID 

the absence of other, organic abdominal lesions to account 
for it, is so invariably found associated with enteroptosis that 
a definite causative relationship cannot reasonably be denied. 
It is true that marked neurotic disturbances are practically 
always present in cases of membranous colitis; but, with the 
facts set forth in mind, I believe the conclusion is a sound one 
that they may properly be regarded as an effect rather than 
causative of the latter. 

The final and strongest argument in support of enteropto- 
sis being a frequent cause of membranous colitis is to be found 
by contrasting the results of treatment. Those who undertake 
the management of these cases by directing their attention 
primarily to the accompanying neurotic phenomena, have little 
else than failure to report and with one accord emphasize the 
intractable nature of the malady; while those who accept the 
mechanical origin and local character of the trouble, and 
direct their treatment accordingly, are able in a large propor- 
tion of cases to afford relief. 

(/) It may be due to disorders or displacements of the 
female generative organs. Now, from 70 to 80 per cent, of 
the cases reported by W. Hale White occur in women, so 
it will not be surprising to find disorders and displacements of 
the generative organs a frequent cause in the production of 
the disease. 

Symptoms. — Those most prominent and constant are con- 
stipation, the passage of large quantities of ropy and mem- 
branous mucus, pains in the abdomen and limbs, and a varied 
assortment of neurotic manifestations. 

Constipation . — These cases are nearly always pre- 
ceded by habitual constipation, which becomes aggravated 
after the membranous colitis begins. Even in those occasional 
cases where diarrhoea is present, it is due to hard scybalous 
masses which are lodged in the saccules of the colon, and pro- 
duce irritation which results in diarrhoea. 

Discharge of Mucus . — The characteristic symp- 
tom of membranous colitis is the discharge of mucus in the 



MEMBRANOUS COLITIS 111 

form of tough tenacious membrane, which may even assume 
the mould of the bowel, or be discharged in large strips ; these 
strips have often been mistaken for the membranous lining 
of the bowel, but they have been definitely determined as 
merely an altered condition of the mucus, which is so tenacious 
as to enable it to retain the mould of the bowel. There is a 
considerable amount of mucus in its ordinary form discharged 
at the same time with this membranous mucus. 

The preceding symptoms are likely to be attended with 
severe griping in the abdomen ; with wandering muscular pains 
in different portions of the body, and a feeling of exhaustion, 
especially in the lower limbs ; both the abdominal pains and 
exhaustion immediately precede and follow the discharge of 
mucus from the bowel. These symptoms may continue for 
several days, to subside for several weeks, when they recur. 
Nearly as characteristic as the discharge of the membranous 
mucus are the neurotic symptoms, such as great mental depres- 
sion, forebodings, and fears, which are nearly always present. 
So constant and pronounced are these symptoms, that they 
have been considered by such good authorities as Nothnagel, 
Ewald, and others to stand in some relation to cause and 
effect. 

Treatment. — The treatment of acute and chronic colitis 
is similar to that of the same condition in the sigmoid. For 
membranous colitis, however, the treatment varies with the 
exciting cause. In all cases the necessity for laxative medi- 
cines is generally conceded ; the best of which seems to be 
castor oil in one-half- to one-ounce doses every morning for 
a considerable length of time. If the stomach will not bear 
the oil, then sulphate of magnesia, or calomel, will be found 
to serve a good purpose. This form of treatment will only 
be likely to succeed in neurotic cases, or in the acute and 
chronic forms of colitis. In those due to inflammatory adhe- 
sions, appendicitis (when not a part of a general colitis), to 
floating kidney, to malignant growths of the large intestine, 
or to disorders and displacements in the female generative 



112 DISEASES OF ANUS, RECTUM, AND SIGMOID 

organs, surgical interference will be found necessary. If 
after opening the abdomen not any of the above cited causes 
are found to exist, and the case has failed to respond favorably 
to a prolonged use of laxative medicine, then it may be found 
beneficial to use the appendix for irrigating the large bowel 
through its entire length. 



CHAPTER V 

ULCERATIONS, SIMPLE AND SPECIFIC 

Included in simple forms of ulceration are those due to 
or infected by non-specific organisms, whether originating 
in traumatism or however produced. In specific ulcerations 
are embraced those due to or infected by specific organisms, as 
syphilitic, tubercular, dysenteric, and actinomycosis. These 
two divisions may be further subdivided according to loca- 
tion, viz. : 

Ulceration of Perianal Region. 

Ulceration of Anal Canal. 

Ulceration of Rectum, Sigmoid, and Colon. 

Simple Perianal Ulcerations. — These are such as occur on 
the surface of the body in other localities and those due to 
causes to which this special part of the body is exposed by 
infection from fecal and vaginal discharges, following lacera- 
tions from hard fecal masses, or from foreign substances, with 
rough surfaces, in such matter. The accumulation of fecal 
matter in those of uncleanly habits will also account for a 
certain number of cases of ulceration. 

The simple ulcerations occurring in this locality may be 
due to traumatism, also to herpetic and eczematous eruptions. 

Traumatic. — Any abrasion of the anal margin by hard 
fecal masses or abrasions by friction from clothing and various 
other causes of the perineal or buttock surfaces are very likely 
to be followed by infection and consequent ulceration, on 
account of the frequent contact of infected fecal matter as 
it passes out of the bowel. 

Treatment. — The treatment consists principally in the 
removal of the cause, that is, the infected fecal matter, by 
absolute cleanliness, and the application of some bland anti- 
septic ointment. 

8 113 



114 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Herpetic. — These occur here, as on other surfaces of the 
body, generally close to the anal margin, resulting from infec- 
tion of herpetic vesicles, by the presence of which this form of 
ulceration is recognized. 

Treatment. — This is similar to that for traumatic ulcers, 
with the addition of tonics and the application of dusting 
powders, such as oxide of zinc and calomel in equal parts. 

Eczematous. — Ulceration from this cause is due to infec- 
tion of abrasions which are generally made by the fingers in 
the effort to allay the itching which attends the eczema. 

Treatment- — Cleanliness and antiseptic powders, especially 
powders containing salicylic and boracic acid. 

Ulceration of the Anal Canal. — While abrasions in this 
locality are exposed to infection from similar causes as those 
around the anal margin, the anatomical conditions are very 
different and the liability to infection much greater. Dr. F. C. 
Wallis has called attention to the fact that " these ulcerations 
occur in the lining membrane of the proctodeum, which is 
neither skin nor mucous membrane, which has not the resist- 
ing power of the one nor the vascular supply which is the great 
resisting power in the other." These ulcerations resemble 
fissures very much in appearance and symptoms. They are 
covered with granulation tissue, exude a thin acrid pus, and 
occur most frequently in the posterior quadrant. 

Symptoms. — Burning pain, much increased during and 
after defecation. This is much greater the nearer it approaches 
the skin margin. Dr. Wallis thinks that pruritus ani is fre- 
quently caused by these ulcerations, as abscesses also may be, 
which occur in the adjoining tissues and the same holds good 
of their resultant fistulas. 

Treatment. — Stretching of the sphincter, slitting up the 
fistulous tracts, taking great care that no sinuses be over- 
looked ; application of the electro- or thermocautery, or strong 
nitric acid. Subsequently the sores should be irrigated with 
antiseptic solutions or pure peroxide of hydrogen should be 
applied twice daily. 



ULCERATIONS, SIMPLE AND SPECIFIC 115 

Ulceration of the Rectum and Sigmoid. — These are more 
frequent in the rectum than in the sigmoid and are of three 
varieties, simple, hemorrhoidal, and follicular. 

Simple ulcerations of the rectum are such as result from 
the abrasion of its epithelial surface by foreign substances, 
especially by hard and dry fecal matter, with subsequent infec- 
tion by the ordinary pus organisms, which are brought in 
contact with the abrasions through the fecal matter. 

There may be certain predisposing causes tending to aggra- 
vate the character of the ulceration by lowering the vitality 
of the surrounding tissues, such as catarrhal inflammation 
(already considered), or a varicose condition of the vessels, 
or age. Some of these causes have been considered sufficiently 
important to designate the ulcers arising from them by their 
respective names, as varicose and catarrhal. I prefer, however, 
to include them all under one heading, and to regard these 
predisposing causes as aggravating conditions. 

There are certain anatomical predisposing causes existing 
in all cases which make the rectum peculiarly susceptible to 
ulceration, such as the absence of valves in the rectal veins 
and the sluggish collateral circulation. Certain organic dis- 
eases may also act as predisposing causes, as herpetic dis- 
orders, valvular disease of the right side of the heart, and 
atheroma of the arteries. 

Certain constitutional diseases may also be included as 
agents, such as Bright's disease, diabetes, and trophic ulcera- 
tions. 

Exciting Causes. — The most usual are traumatism and the 
toxic action of certain drugs. 

Symptoms. — While these are very similar for all varieties 
of ulceration they differ very materially in severity, depending 
not so much upon the size of the ulcer as upon its location ; 
those located nearest the sphincter produce the most distress- 
ing symptoms. Diarrhoea is one of the earliest and most 
important symptoms ; the stools soon become composed of 
mucus, pus and blood, and are attended with tenesmus and 



116 DISEASES OF ANUS, RECTUM, AND SIGMOID 

bearing down. Incontinence of faeces may exist. If the ulcer 
is attended with a varicose condition of the superior hemor- 
rhoidal veins it is likely to result in severe and even fatal 
hemorrhage, and to be covered with a thick yellowish pus. 

Treatment. — The sphincter should be either thoroughly 
stretched or incised in order to facilitate thorough drainage 
and irrigations made with antiseptic solutions, three or four 
times daily. Stimulating applications, once daily, should be 
made directly to the ulcer, with a 2 or 5 per cent, solution of 
nitrate of silver, or a 20 per cent, solution of argyrol. The 
irrigations will keep the rectum free from fecal matter. To 
allay the irritability of the rectum it may be necessary to use 
an ointment composed of opium, hyoscyamus and belladonna 
in a collapsible tube with a nozzle, which is more convenient 
than suppositories. The patient should be confined to the 
recumbent posture while the tenesmus and bearing down con- 
tinue. If the ulcer is attended with a varicose condition of 
the veins, it is better to elevate the hips for a considerable 
time before pus has time to form and gravitate up the bowel. 

Hemorrhoidal Ulcers. — These are due to thrombosis of 
the hemorrhoidal vessels, complete obstruction of the circula- 
tion, with consequent necrosis, and the formation of an ulcer 
or a distinct hemorrhoidal tumor. They may also follow the 
abrasion and infection of an acutely inflamed hemorrhoid, or 
from the injection into the hemorrhoid of some corrosive sub- 
stance, with the object of destroying it. The history of acutely 
inflamed hemorrhoids with the location of the ulcer on one 
of them is the most striking characteristic of this form of 
ulcer. Severe pain and frequently a rise of temperature in 
the early stage is present until the abscess cavity breaks, the 
pus is discharged, and the ulcer forms. The pain, however, 
soon returns and is attended with tenesmus and spasm of the 
sphincter. 

Treatment. — This consists of complete removal of the 
hemorrhoidal mass together with the ulcer. If care is taken 
to thoroughly cleanse the ulcer, with the adjoining tissue, and 



ULCERATIONS, SIMPLE AND SPECIFIC 117 

make it thoroughly aseptic, the wound may be closed by 
sutures, or, better, the mass may be removed by the clamp 
and cautery and the wound left to granulate. 

Follicular Ulceration of Rectum and Sigmoid. — 
These ulcerations result from the breaking down of follicles 
in follicular proctitis, or sigmoiditis. Varying in size from a 
millet-seed to a hazel-nut ; they may be single or multiple. As 
the ulcer involves the submucous layer and its orifice is con- 
stricted (which interferes with its draining properly) these 
ulcers are liable to perforate the intestinal wall. For the 
same reason they may become distended with fecal material 
and form diverticula. 

Symptoms. — Beyond the occasional discharge of small 
quantities of pus, sometimes tinged with blood, with some 
griping and tenesmus, there are no other symptoms to direct 
us to the condition and examination through the proctoscope 
is the only reliable and positive means of making a diagnosis. 

Etiology. — Not definitely known. 

Treatment. — Local stimulating applications should be made 
daily directly to the ulcers, through the proctoscope; and irri- 
gations with antiseptic solutions used twice daily in the knee- 
chest position if the ulcers are high up. If the ulcerations be 
multiple, obstinate, and extend up into the colon, it may be 
advisable to do an appendicostomy and irrigate the large 
intestine throughout. 

Ulceration Attending Stricture. — This form of 
ulceration differs from the traumatic only in the character of 
the pathological lesions. The fibrous infiltration of the walls 
of the bowel, with the consequent interference with its circu- 
lation; the narrowing of its lumen, and the friction of the 
retained hardened fecal masses, combine to produce this ulcera- 
tion just above the stricture, where the effect of the pressure 
and friction from the fecal mass is longest continued. In 
syphilitic strictures we have two additional causes, namely, the 
action of the syphilitic virus on the vessel walls producing 



118 DISEASES OF ANUS, RECTUM, AND SIGMOID 

arteriosclerosis, and the constitutional effects of the disease, 
which lowers the vitality of the patient, making the liability 
to ulceration more likely. 

Symptoms. — Bearing down, frequent and often ineffectual 
desire to defecate, with the discharge of a mucopurulent matter 
sometimes tinged with blood. 

A further consideration of this form of ulceration, with 
its pathology and treatment, will be found under " Strictures 
of the Rectum." 

The form of ulceration that attends the breaking down of 
carcinomatous growths should always be borne in mind and 
can be recognized by the characteristic symptoms of this dis- 
ease, which will be found under it own subject heading. 

Ulcerations that frequently occur in connection with such 
diseases as Bright's disease, diabetes, and chronic cirrhosis 
of the liver, are similar in their etiological factors to simple 
traumatic ulcerations. These attendant diseases merely act as 
predisposing causes, lowering the resistance of the tissues, 
and should be treated locally as simple ulcerations, the pre- 
disposing disease at the same time receiving its proper care 
and attention. 

SPECIFIC ULCERATIONS 

Specific ulcerations of the anus, rectum, and sigmoid are 
those due to a specific organism. Those ulcerations traceable 
to such a cause are : Tubercular, Dysenteric, Venereal, Diph- 
theritic, Carcinomatous, Bilharzia Haematobium, and Actino- 
mycosis. 

Tubercular Ulceration of the Anus, Rectum, and Sig- 
moid. — The discovery of the tubercle bacillus led to its recog- 
nition as the cause of many forms of ulceration in the anal 
and perianal regions, the pathology of which was formerly 
unknown. These ulcerations may be either primary or sec- 
ondary. They may be propagated either by the blood-vessels 
to the adjoining tissues, or through the lymphatics, and advance 
in an inverse ratio to the amount of fibrous tissue in their path. 



ULCERATIONS, SIMPLE AND SPECIFIC 119 

Pure cicatricial tissue forms an impassable barrier to their 
progress, a very important fact to be borne in mind by the 
surgeon when dealing with these ulcerations, lest he should 
cut through these barriers established by nature. 

Tubercular Ulceration of the Perianal Region. — Where 
traumatism has occurred and the wound is exposed to tuber- 
cular infection the tubercular process may proceed under one 
of four types, namely, miliary, ulcerative, lupoid, and papillary, 
or verrucous ulceration. 

Miliary Type. — This very rare type is seen almost entirely 
in connection with general tuberculosis. It develops in minute 
nodules, or tubercles, that feel like millet-seed under the sur- 
face. They are always multiple. Several of these tubercles 
coalesce, caseation, then ulceration, follows ; the overlying 
tissues become involved and break down and the ulcer forms. 
These ulcers are at first shallow cup-shaped, with ragged edges. 
Several are likely to coalesce and form extensive ulcers, whose 
character is determined by finding the tubercle bacilli in the 
scrapings from them. 

Treatment. — The local treatment consists in keeping the 
ulcers perfectly clean and by gentle stimulation of the surfaces, 
with a 25 per cent, solution argyrol, pure ichthyol, or by dust- 
ing it with boracic acid and iodoform. Special attention should 
be paid to the patient's general condition, keeping him well 
nourished and with plenty of fresh air. 

The Ulcerative Type. — All tuberculous processes of the 
superficial integuments take on the ulcerative stage sooner or 
later. The usual tubercular process of infection, caseation, 
and suppuration, is followed in this type of ulceration. These 
ulcers are generally secondary, although they may be primary. 

Diagnosis. — The finding of the bacillus in the scrapings. 

Treatment. — Extreme cleanliness, antiseptic washes, or 
antiseptic dusting-powders, with the general constitutional 
treatment referred to above. The patient should not be con- 
fined to bed. 



120 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Malignant Ulceration of the Perianal Region. — See chapter 
on Carcinoma. 

The rodent ulcer, so graphically described by Dr. 
Allingham, and referred to by other authors as a distinct 
variety of ulceration, has now been definitely classified as a 
malignant form of ulceration. 

Tubercular Ulceration of Anal Canal. — In this locality it 
resembles very much a simple irritable ulcer or fissure, except 
that its borders are irregular and undermined and more indu- 
rated at its base, the latter a provision by nature to stay the 
progress of the disease. 

Lupoid Ulceration of Anal Canal. — This is only another 
form of tuberculosis, with considerably more infiltration 
beneath and around it; while this infiltration retards its 
progress, yet eventually it is very destructive to the tissues 
and obstinate in resistance to treatment. 

Verrucous Ulceration. — This is still another type of 
tubercular ulceration, its chief characteristic being its papil- 
lary or mammillated appearance. Now that the finding of the 
tubercle bacilli in each of these forms of ulceration is the chief 
essential, little attention need be paid to these names ; it is only 
necessary to establish the fact that they are tubercular. 

Treatment. — Here, as in tuberculous ulcerations elsewhere, 
all unnecessary surgical interference should be avoided. Ex- 
treme cleanliness, with mild antiseptic irrigations, gentle 
stimulation of the w T ound, and thorough drainage, is the best 
that can be done for the local trouble. In the lupoid form of 
ulceration gentle curettage, followed by X-ray with general 
constitutional treatment gives the best results. The treatment 
of the verrucous form should be similar to that of simple 
tubercular ulceration. 

Tubercular Ulceration of the Rectum and Sigmoid. — 
While infection of the intestinal walls may take place by the 
bacilli invading the solitary follicles, yet it is probable 
that it more frequently occurs through an abrasion of the 



ULCERATIONS, SIMPLE AND SPECIFIC 



121 



mucous surface. The ulcers may be round or elliptical in the 
beginning, but soon spread and become large irregular patches, 
following chiefly the course of the blood-vessels, hence in the 
lower portion of the rectum spreading in all directions, in 
the upper portion horizontally, in the sigmoid having a ten- 
dency to encircle the bowel (Fig. 36). The healing of such 
a horizontal ulcer explains the formation of stricture from 
tubercular ulceration. 

Stricture from tubercular ulceration may not only follow 
the horizontal form of ulcer but those in the rectum that may 
spread in any direction ; one reported case of which I give : 




Fig. 36. — Tubercular ulceration encircling the sigmoid. 



R. F. W., age thirty-two, presented himself August I, 1908, 
with stricture of the rectum. About ten years ago he was 
injected for hemorrhoids, probably with a sol. acid carbolic 
by a quack. The injection was followed by excessive pain 
and a large swollen tumor, which subsided after several weeks. 
About one year afterwards he was operated on by a general 
surgeon, who did what appeared from the scar to be a proc- 
totomy. The stricture had gradually closed until the opening 
was only about one-half inch in diameter; stools frequent and 
attended with a great deal of tenesmus. I did a resection, in 



122 DISEASES OF ANUS, RECTUM, AND SIGMOID 

which I was able to save both sphincters, making my lower 
circular incision just above the internal sphincter. The opera- 
tion was very successful, the wound healed promptly, and the 
patient has almost complete control over the sphincters. Path- 
ological findings showed great fibrous thickening of the walls 
of the bowel, with numerous tubercles. 

Symptoms. — The symptoms of tubercular ulceration of 
the rectum and sigmoid will be influenced largely by the loca- 
tion and extent of the ulceration; if low down in the rectum 
there will be decided tenesmus, straining and frequent stools; 
if high up, frequent stools with a discharge of mucus, pus, and 
blood; as the ulceration extends, the tenesmus and diarrhoea 
increase and are attended with loss of appetite and great 
emaciation. 

Diagnosis. — The findings of the tubercle bacilli, together 
with the presence of giant cells in the tissues from the base of 
the ulcer, are the essential characteristics. 

Treatment. — Antiseptic irrigations, with special attention 
to general treatment, is the best that can be done. Good 
results have followed appendicostomy in several cases that 
have been reported. 

Acute Tubercular Proctitis. — I reported {Maryland Med- 
ical Journal, 1887) three necropsies in which this very inter- 
esting condition existed. It was while working under Dr. 
William T. Councilman at Bayview Alms House, that he 
demonstrated the cases to me. Later, in 1899, I reported 
{Baltimore Medical College Alumni Journal) two clinical 
cases of the same condition which I saw and treated. 

The condition as found in the rectum is characterized by 
swelling of the mucous membrane, intense hypersemia, and 
numerous small ulcers. The microscopical appearance of the 
ulcers in the three cases in which autopsies were made offered 
many points of interest. In most cases anatomic tubercles 
were found in or about the ulcers. There was an intense 
small-cell infiltration of the mucous and submucous coats. 
Many of the glands of Lieberkiihn were filled with cells. 



ULCERATIONS, SIMPLE AND SPECIFIC 123 

Where the small-cell infiltration was greatest, the tissues did 
not stain brilliantly and appeared as if in the condition of 
beginning caseation. Some of the cells were large, pale, and 
epithelioid, similar to those filling the alveoli of the lung in 
caseous pneumonia. In a few sections well-defined tubercles 
with giant-cells were found, and sometimes aggregations of 
small cells with a caseous centre. On staining the sections for 
tubercle bacilli, enormous masses of these were found in the 
edges of the ulcers. In some places they were found in the 
infiltrated mucous membrane, where as yet there was no 
breaking down and where the small-cell infiltration was the 
only pathological condition. Where found in greatest abun- 
dance, caseation and destruction of tissue accompanied them. 

This condition of the rectum seems to be an important 
point, for it shows that the tuberculous process in mucous 
membranes, as well as in the lungs, can advance independently 
of the formation of miliary tubercles. It is interesting to note 
also the similarity between the large cells found here and in 
caseous pneumonia. In the rectum, in these cases, just as in 
the lung, we have to do with an inflammation on which a 
specific character is impressed by the presence of the bacilli. 
Here is one of the clinical cases of acute tubercular proctitis 
seen by me : 

H. G., age sixteen, American. Urinary analysis normal; 
came into the Maryland General Hospital, May 26, 1899, 
complaining of a burning in the rectum, with an inflamed tag 
at the anal orifice. Family history good, no tuberculosis 
having been present. Physical examination of the chest by Dr. 
O'Donovan showed nothing abnormal ; no cough, or fever. 
Upon examination into the rectum with a speculum, I found 
the .mucous membrane very red, inflamed, and discharging pus. 
I suspected gonorrhceal proctitis, at the same time recognizing 
the same appearance as seen in the rectum of the three cases 
of acute tubercular proctitis I have mentioned. The redness 
of the mucous membrane was marked ; it was granular and 
looked like a piece of red flannel. I ordered the pus examined 



124. DISEASES OF ANUS, RECTUM, AND SIGMOID 

for gonococci, with negative results, but tubercle bacilli were 
found in great abundance ; subsequent examinations confirmed 
this diagnosis. I ordered injections of a saturated solution of 
boracic acid three times daily; subsequently used injections of 
a solution of sodium chloride. He left the hospital June 18, 
1899, entirely relieved, with no tubercle bacilli to be found in 
the discharges from the rectum. He was ordered to report 
again at the hospital, if he had any return of the local trouble, 
or if he had any general sickness. He had not done so up 
to October, 1899. 

Dysenteric Ulceration. — This is an acute specific inflam- 
mation of the solitary glands and follicles of the large intes- 
tine, which if unchecked soon results in ulceration. While it 
may occur throughout the large intestine, yet in a large 
majority the ulceration is found in the rectum and sigmoid 
and often confined to these localities. 

Etiology. — Dysentery is now generally admitted to be 
due to a specific micro-organism. Three types of the disease 
exist, the amoebic, the bacillary, and that due to a mixed infec- 
tion, which might be classed as simple ulceration. The term 
catarrhal dysentery is no longer recognized. 

The amoebic and bacillary forms are not confined to trop- 
ical climates, as formerly supposed, but are frequently found 
in the temperate also. 

Bacillary Dysentery. — This type is due to infection by 
the Shiga bacillus (Bacillus dysenterise) or one of its proto- 
types, and Shiga describes the bacillus as a short rod with 
rounded ends, much resembling the Bacillus typhosus, or the 
greater portion of the colon group. By what means it gains 
admission to the intestinal canal is not yet definitely known. 

Symptoms. — It is frequently ushered in with a chill, rise of 
temperature, griping abdominal pains, tenesmus, and a burning 
in the rectum. The stools, at first mushy, then watery, are 
finally composed almost entirely of mucus and blood. Fre- 
quently there is nausea, and collapse often comes on early in 
the course of the disease; emaciation is very rapid. 



ULCERATIONS, SIMPLE AND SPECIFIC 125 

The constitutional symptoms are due to toxins produced 
by the specific bacilli and not by the bacilli themselves. No 
report of the proctoscopic findings in this form of dysentery 
have been made. The autopsies, however, show the infection 
to be superficial, and the area of infection large; the ulcers to 
assume an irregular form and the lesions in the acute stage to 
be confined to the lower portion of the colon. The ulcers in 
their chronic form show a decided tendency to contract upon 
healing. Convalescence is very slow and relapses very 
frequent. 

Treatment. — A large dose of calomel gr. x, with bicar- 
bonate of soda, should if possible be given early in the disease; 
this to be followed in six hours by one ounce of castor oil. 
When this has acted well, give rectal irrigations of warm 
unirritating antiseptic solutions every four or five hours. 

Shiga has had very good results from the serum treatment. 
According to Dr. Eldridge, up to November I, 1899, he treated 
the following number of cases with serum: In 1898 in Lab- 
oratory Hospital, 65 cases; death-rate, 9 per cent.; 1899, i n 
Laboratory Hospital, 91 cases; death-rate, 8 per cent.; 1899, 
in Hirowo Hospital, no cases; death-rate, 12 per cent. Dur- 
ing the same period of 1899 there were under ordinary treat- 
ment at Tokyo, Honjo Hospital, 166 cases; death-rate, 37.9 
per cent.; at Hirowo Hospital, 53 cases; death-rate, 37.7 
per cent. ; at Komogome Hospital, 398 cases ; death-rate, 
34.6 per cent.; in private houses, n 19 cases; death-rate, 28.5 
per cent. With the use of the serum it will still be necessary to 
give the constitutional treatment and the rectal irrigations. 

Amcebic Dysentery. — This form of ulceration is due to 
infection by amoeba dysenteric. Musgrave and Clegg suc- 
ceeded in cultivating amoebse from different sources, and 
among the most striking peculiarities of these amoebae is that 
of not growing except in connection with other organisms 
(symbiosis). Neither the two authors named, nor any one 
else as yet, have been able to get pure cultures of amoeba with- 
out a symbiotic micro-organism. A micro-organism is indis- 



126 DISEASES OF ANUS, RECTUM, AND SIGMOID 

pensable to the propagation of these protozoa. Not only must 
they have growing in connection with them a micro-organism, 
but it must be of a character with which they may affiliate ; in 
other words, they have a selective power for special bac- 
teria, this selectiveness being particularly marked in amoebae 
from the human intestine, and a fact equally true whether 
they have been brought to these places by natural means or by 
experiment. Nor need they necessarily be a pathogenic organ- 
ism, although those most frequent found associated with them 
in amoebic ulceration of the intestines are the colon bacillus, the 
Spr. cholera, and the Bacillus typhosus. The distribution of 
amcebse and the source from which they may be obtained have 
been found to be very general — the soil, both surface and deep, 
marshes and stagnant water, air, grasses, and fruits. While 
all amoebae from the above sources have heretofore been looked 
upon as non-pathogenic, yet Musgrave and Clegg have suc- 
ceeded in producing amoebic dysentery from some obtained 
from these sources nor have they been able to discriminate 
morphologically, or from their culture, any difference between 
the pathogenic and non-pathogenic varieties. 

An unusual form of amoebic dysentery is reported by 
Harry T. Marshall, of Charlottesville, Virginia, the speci- 
men shown being obtained from a male Filipino who died from 
intestinal hemorrhage after being ill but ten days or two weeks : 

The whole colon was studded with nodules up to 12 or 15 
mm. in diameter, the tops of some being necrotic. Micro- 
scopically the mucosa over the nodules was lost and fibrin and 
leucocytes extended into the submucosa. The nodules con- 
tained many amoebae, but no bacteria. I have found no other 
specimen of this type, even in museums, and but few writers 
mention such a condition. I regard it as an early case which 
lacked the extensive necrosis and ulcer formation so commonly 
seen. 

Character of the Ulceration. — In the chronic form, 
when the ulcers are well defined, they are single and retain 
individuality even when clustered; they are raised above the 



ULCERATIONS, SIMPLE AND SPECIFIC 127 

level of the mucous membrane, with a yellowish centre, which 
is slightly depressed, very much resembling miniature prairie- 
dog mounds; the surrounding mucous membrane is red and 
inflamed. The yellow gelatinous mass which forms the centre 
of the ulcer contains the amoebae, and there is excessive secre- 
tion of mucus. 

Location of the Ulcers. — Most authors affirm the 
caecum and ascending colon to be the chief sites of the lesions, 
and most likely their opinion is based upon the findings at 
autopsies. The rectal specialist, seeing these cases during 
•life through the proctoscope, finds in nearly every case the 
ulceration in the rectum and sigmoid, and in the average case 
there are no symptoms in the caecum and ascending colon to 
attract his attention. In aggravated cases, especially those 
that have had frequent remission, they extend to the caecum, 
or rather that has been the primary location, and this doubtless 
accounts for the remissions and explains the rapid recovery 
following antiseptic irrigations through the appendix, even 
after having resisted, for a long time, similar irrigations per 
rectum. 

Diagnosis. — While the description of the ulcers given 
above is very characteristic, the only reliable diagnostic sign 
is in finding the amoeba, and the only accurate method of 
doing this is by examining the scrapings taken directly from 
the ulcers and examining them immediately under the micro- 
scope. 

Symptoms. — There may be slight elevation of temperature, 
which is likely always to be present in acute cases, tenesmus, 
frequent stools with the discharge of mucus and pus, and 
which are sometimes streaked with blood. Various writers 
have pointed out that amoebic infection may exist in a latent 
form and prove fatal from complications without noticeable 
diarrhoea and sometimes even with constipation. Severe con- 
stitutional symptoms are rare, except by involvement of the 
liver with amoebic abscesses. There is likely to be considerable 



128 DISEASES OF ANUS, RECTUM, AND SIGMOID 

emaciation. A leading characteristic is irregularity in course ; 
for it is made up of intermissions, relapses, and exacerbations. 

Treatment. — Let all efforts be directed towards eradicating 
the disease by local measures, as by frequent antiseptic irriga- 
tions, certain of which have been found to have a specific 
action on the growth of the amoeba. Musgrave and Clegg 
found that amoebae grow very slowly at the temperature of 
the ice-box, but have been unable to verify the usual statement 
that these amoeba always lose their motility at or below 75 ° F. 
in stools, and certainly such is not the case in cultures. Kreuse 
and Pasquale were able to produce dysentery in cats by using 
faeces containing amoebae which had been frozen and thawed, 
and from this they inferred that dysenteric amoebae are prob- 
ably not destroyed at a temperature somewhat below o C, 
hence the temperature of the irrigations need not be regarded. 

Among the solutions for irrigation which have been found 
most efficacious are, first, quinine from 1 to 300 to 1 to 1000, 
which according to Musgrave and Clegg cause the amoebae to 
become encysted, and only scant growths of amoebae were 
obtained from the emulsion ten minutes after the quinine solu- 
tion had been added. According to the same authors, solutions 
of formalin 1 to 1000 were only partially successful, the para- 
sites becoming quickly encysted, but in twenty-four hours a 
small number of amoebae developed from transplants. Clin- 
ically Dr. John J. Jelks, of Memphis, has used the solution of 
formalin with great success, using as strong a solution as 
1 to 500, adding to the solution the same proportion of pure 
carbolic acid. He thinks the addition of the acid lessens the 
irritation from the formalin. He uses this irrigation once a 
day and continues to do so from one to two months. Solu- 
tions of nitrate of silver from / 2 to 1 per cent, used every 
alternate day for several weeks have been found very bene- 
ficial. If the use of either or all of these remedies fails to 
relieve the patient at the end of six or eight weeks, or if after 
getting better there are recurrences, it is well then to resort 
to valvular caecostomy, or appendicostomy, without delay. The 



ULCERATIONS, SIMPLE AND SPECIFIC 129 

diet should be principally nitrogenous, and of a mild unirri- 
tating character; the patient should be confined to bed. 

The need for csecostomy, or appendicostomy, in the obsti- 
nate and chronic cases is due to the fact pointed out first, we 
think, by Rogers, that the caecum and ascending colon are 
frequent sites of these lesions. Irrigation of these parts of 
the large intestine through the rectum is impracticable and 
decidedly inefficient, for physical causes, it being impossible 
to flush thoroughly the blind end of any canal. The reasonable 
objections to the usual colostomy opening, which was formerly 
used for this purpose, have been overcome; first, by the sug- 
gestion of Dr. Gibson through his operation known as val- 
vular caecostomy and secondly, by the suggestion of Dr. 
Robert F. Weir of using the appendix for the purpose of irri- 
gating the intestinal tract below this point. In view of the 
eminently satisfactory results of irrigation through either of 
these openings, the ease and safety with which the openings 
can be closed and the absence of leakage of the intestinal con- 
tents, we do not hesitate to recommend one of them in every 
case of obstinate amoebic ulceration that has failed to respond 
to the usual methods of local treatment through the rectum. 
Cases of venereal, dysenteric, and tubercular ulceration of 
the large bowel have been successfully treated by this method ; 
also a variety of cases due to autointoxication of intestinal 
origin. 

Valvular Cecostomy. — This operation was devised prior 
to appendicostomy and, while the latter may be more attrac- 
tive and at first sight appear easier to perform, there are a 
number of objections to appendicostomy that make csecostomy 
the operation of choice. Some of the objections that are urged 
against appendicostomy are that the lumen of the appendix 
is frequently obliterated, and its position at the end and lower 
portion of the caput coli necessitates such traction upon it in 
order to bring it out through the abdominal opening that its 
circulation is often interfered with to such an extent as to 
cause sloughing of the entire appendix, even where the appen- 

9 



130 DISEASES OF ANUS, RECTUM, AND SIGMOID 

diceal artery has not been tied. The conditions that favor 
caecostomy are that the portion of the caecum to be opened is 
directly in contact with the anterior abdominal wall, where 
the external opening is to be made; that the opening in the 
caecum may be made directly opposite the ileocecal valve 
through which a tube can be carried for the purpose of irri- 
gating the ileum, and the leakage from the caecum can be 
controlled equally as well as when the appendix is used. 




Fig. 37. — Gibson's method showing catheter introduced into the caecum. 

Dr. Gibson's method (Boston Medical and Surgical Jour- 
nal, Vol. cxlvii, page 341) is as follows: An incision one and 
one-half inches long is carried through the abdominal wall 
parallel with Poupart's ligament on the right side, and one 
inch internal to its outer part. The caecum is found directly 
beneath, and presents itself in the opening. A point is chosen 
in its anterior band and the intestine is opened sufficiently to 
admit a fair-sized soft rubber catheter (Fig. 37). Three 
tiers of sutures placed above and below this orifice serve to 



ULCERATIONS, SIMPLE AND SPECIFIC 



131 



infold the csecal wall. The ends of the last sutures introduced 
are left long and are carried through the margins of the 
abdominal incision; these when drawn tight bring the caecum 
forward into close contact with the abdominal wall, and are 
further utilized to close the external wound, being reinforced 
by a silkworm-gut suture in each angle (Fig. 38). The 
catheter is left in until the seventh day, after which it is rein- 
troduced at the time of each irrigation; the latter is begun 




Fig. 38. — Gibson's method showing the wound closed with catheter in the caecum. 

about the second or third day after the operation. There is 
absolutely no leakage from this opening when the catheter is 
out, nor is there any difficulty attending its reintroduction ; 
the wound readily closes of itself, after the use of the catheter 
is stopped. 

Samuel G. Gartt, of New York, has devised what he believes 
to be a new and effective way of irrigating both the small and 
large intestine through the same opening in the caecum — an 
operation which he designates Ccccostomy with an arrange- 



132 DISEASES OF ANUS, RECTUM, AND SIGMOID 

ment for irrigating both the small intestine and colon {New 
York Medical Journal, Aug. 15, 1908). Gant believes his 
caecostomy to be superior to that suggested by Gibson, because 
the technic is equally as simple, the operation requires no more 
time, there is less leakage owing to the purse-string suture 
being substituted for his lateral infolding sutures, both the 
small and large bowel can be irrigated by the attendant or 
patient, a firmer support is obtained by attaching the caecum 
to the transversalis fascia than when it is stitched to the 
parietal peritoneum, and the opening heals spontaneously after 
the catheters are removed. 

The following is a brief description of his method with 
his special appliance for the purpose (Fig. 39) : 

First Step. — Through a two-inch intermuscular incision 
made directly over the caecum it and the lowermost part of 
the ileum are withdrawn, and the edges of the wound covered 
with sterile gauze handkerchiefs. 

Second Step. — The caecum is scarified and clamped with 
rubber-covered forceps to prevent soiling the wound when the 
bowel is opened (Fig. 40, C). 

Third Step. — Four lines of silk seromuscular purse-string 
sutures are inserted in the anterior wall of the caecum, at or 
outside the longitudinal band directly opposite the ileocaecal 
valve (Fig. 40, F), when the bowel is quickly opened inside, the 
suture line by using the knife for the outer coats and scissors 
for the mucosa. 

Fourth Step. — The bowel is grasped at the juncture of 
the large and small intestine, and is held in such a way that 
the ileocaecal valve rests between the thumb and fingers of 
the left hand (Fig. 40). A Gant enterocaecal irrigator (Fig. 
39 2 or catheter carrier Fig. 40, B) is then introduced through 
the incision, and carried directly across the caecum, and then 
quickly guided through the ileocaecal valve into the small 
intestine by the aid of the thumb and fingers, placed there for 
this purpose (Fig. 40). 




*J 



Fig. 39. — Steps showing Gant's caecostomy, which provides for irrigation of both the 
small and large intestine. 1. Shows apparatus in position. 2. Side view of Gant's entero- 
caecal irrigator. 3. Front and sectional view of the same, (a) Irrigating tube, (b) Inflating 
attachment, (c) Clip for closing same, (d) Shows inflating bag distended with air to 
prevent return of solution into the caecum, (e) Cover for irrigator. The celluloid rod 
shown on the right of (2) is used as a guide for removing and the reintroduction of the 
irrigator when it becomes necessary to change the inflating bag. 



ULCERATIONS, SIMPLE AND SPECIFIC 133 

Fifth Step. — The inflating-bag (Fig. 39, D) on the end of 
the irrigator is then distended in order to hold the irrigator in 
place until the purse-string sutures are tied. 

Sixth Step. — The clamp is now removed from the caecum 
and the purse-string sutures are tied (Fig. 40, F) ; this inverts 




Fig. 40. — Showing the different steps in Gant's caecostomy, in which either the rubber 
catheter or his special apparatus can be used. A, catheter; B catheter-carrier; C, rubber- 
covered clamps; F, four rows of purse-string sutures. 

the edges of the bowel about the tubes, each stitch in its turn 
causing a still further circular infolding of the bowel, together 
forming a cone-shaped valvular projection all around the irri- 
gator, which effectually prevents the escape of the faeces. 
Seventh Step. — The caecum is scarified and anchored to 



134 DISEASES OF ANUS, RECTUM, AND SIGMOID 

the abdominal wall by through-and-through suspension sutures, 
or by chromicized catgut stitches, which include the trans- 
versalis fascia. The wound in the abdomen is closed by the 
layer method, after which the metallic plate is held close to 
the abdominal wall by tapes passed around the body and 
attached to the holders at each end of the plate. 

Remarks. — In order to avoid the danger of infecting the 
wound, irrigation is not begun until the second day, unless 
there is some special reason for greater haste. 

After the diarrhoea or ulceration has been cured, and when 
spontaneous healing permits the withdrawal of the irrigator, 
the opening may be closed by cauterizing the mucous surfaces, 
or by taking several sutures under local anaesthesia without 
entering the peritoneal cavity. 

In the absence of the special mechanism for doing Gant's 
caecostomy, two pieces of catheter, one for the caecum and one 
for the ileum, may be substituted for the irrigator, in which 
case it is necessary first to introduce a Gant's catheter-carrier. 
(Fig. 40, B.) 

Gant has obtained some wonderful results in the treatment 
of anaemia by means of small and large intestinal irrigation, 
and is satisfied that attacks of typhoid fever could be short- 
ened and made less severe by this operation, and that patients 
suffering from ptomaine poisoning and cholera could like- 
wise be benefited. 

The technic of Weir's operation for appendicostomy as 
modified and given by Tuttle in a paper read before the 
Surgical Section, New York Academy of Medicine, May, 1905, 
is as follows : An incision one and one-half inches long is 
made at McBurney's point, the intermuscular method being 
used. The appendix having been found and brought out to 
the surface, its artery is tied (I do not approve of tying the 
artery) and the mesentery stripped down to its juncture with 
the caput coli ; a suture is then passed at the lower angle of 
the wound through the peritoneum, then through the mus- 
cular walls of the caecum at its juncture with the appendix, 



ULCERATIONS, SIMPLE AND SPECIFIC 



135 



and back through the peritoneum on the opposite side of the 
wound ; a second suture is then passed about half an inch above 
the other through the same tissue, but on the upper side of 
the appendix (Fig. 41). These two sutures being tied the 
peritoneum is closed by continuous suture, and the wound in 
the usual manner, the skin being sutured accurately but not 
too tight. The patulousness of the appendix should be 
definitely determined before closing the abdominal wound. 




Fig. 41. — Tuttle's modification of Weir's appendicostomy. a, b, sutures fixing cscum to 
parietal peritoneum; c, sutures fixing appendix to skin. (Tuttle, Amer. Jour, of Surgery.) 

If there is any real reason to doubt its patulousness, we think 
it better to cut off the end and tie in a very small catheter 
before closing the peritoneal cavity (Fig. 42). 

Gant has devised a special irrigator (Fig. 43) to be used 
in such emergencies, and advises that it should always be 
used and that it should be made the rule to open the appendix 
at once. The author is quite in accord with this practice. 

There is very little risk in this, and it gives the surgeon 
the advantage of performing a 'valvular coecostomy at once 



136 DISEASES OF ANUS, RECTUM, AND SIGMOID 

if the appendix proves to be impervious. It is better to 
delay the irrigations four or five days after the operation, 
on account of the liability to infect the wound. Irrigations 
through either of these openings are very easily accomplished 
through the catheter. A No. 12 French soft-rubber catheter 
is the size used for introducing into the appendix. This 
can be left in continuously for several weeks, but as soon 




Fig. 42. — Showing catheter in position and ligature which tied around the stump of 
the appendix, prevents leakage and eventually amputates it. (Tuttle, Amer. Jour, of 
Surgery.) 

as the rubber becomes hard from the secretions it is likely 
to irritate the opening and a fresh one should take its 
place; or when such irritation occurs from the catheter it 
can be left out, to be inserted at each irrigation. Gant 
also makes the following suggestions : The solutions for 
irrigation to be used through these openings are similar to 
those that have been recommended for use in the rectum. 
While allowing the solution to run in through the appendiceal 




Fig. 43. — Steps showing Gant's appendicostomy which provides for immediate irri- 
gation of the bowel in cases of ulcerative colitis. 1. Gant's appendiceal irrigator. 2. Caecum 
and appendix in position. 3. Method of ligating the appendix about the irrigator and 
closure of the wound. 4. Shows the irrigator in place and the attached pieces of tape which 
pass around the body and retain it in place while tied and also the rubber tube across which 
the suspensory stitches CC are tied. A, shows peritoneum removed and the gut being 
brought in contact with the transversalis fascia. B. tube attached to irrigator. C, suspen- 
sory sutures which attach the scarified caecum to the abdominal wall. 



ULCERATIONS, SIMPLE AND SPECIFIC 137 

opening the patient is to be placed on a bed-pan and a nozzle 
of a syringe, or a rectal irrigator, introduced into the rectum 
so that water may pass out directly without being allowed to 
distend the rectum and give rise to straining. Irrigations can 
be used to advantage several times during the twenty-four 
hours, as it keeps the bowel free from accumulation of the 
organisms and is attended with so little distress to the patient. 
With few exceptions improvement in the patient's intestinal 
symptoms almost immediately follows the irrigations through 
one of these openings, and a cure is generally effected in from 
three to four weeks. 

Closure of these Openings. — These openings have a ten- 
dency to close themselves whenever the catheter is left out for 
any length of time, but should they fail to do so after a reason- 
able length of time, and the patient wishes it, closure can be 
readily done by cauterizing the opening with a thermo or 
electric cautery. As the annoyance from either of these open- 
ings is so very slight, and the liability for recurrence is so 
great, I have generally recommended that they should be 
kept open indefinitely. I had a case that remained well for 
three years after closure of the opening, who subsequently 
had a recurrence and died from it. Trichomonas intestinalis 
were found in great numbers in one case treated by me through 
the appendiceal opening after the amoeba had disappeared. 

Ulceration Due to Mixed Infection. — The character 
of the ulceration from this infection is very similar to that 
from the bacillary type, except that the symptoms are not as 
a rule so acute or violent. 

Pathology. — The pathogenic organism found in this form 
of ulceration is usually the colon bacillus. 

Treatment. — This is similar to that recommended in the 
bacillary type. 

Venereal Ulceration of the Anus and Rectum. — 
While this form of ulceration is not very frequent in the 
United States, as the direct result of transmission through the 
practice of sodomy and paederasty, yet quite frequently it 



138 DISEASES OF AXUS, RECTUM, AND SIGMOID 

results from autoinfection. The chief varieties are gonor- 
rhceal, chancroidal, and syphilitic. 

GONORRHCEAL PROCTITIS AXD ULCERATION. This form 

resembles acute catarrhal proctitis so closely that it can only 
be differentiated by the presence of the gonococcus to which it 
is due, and by the presence of which it is diagnosed. 

Most of the cases reported have been in the female and 
are secondary to an infection of the genital tract, although 
Lockyer (Dr. Alfred J. Zobel, San Francisco, California) 
asserts on the contrary that gonorrhoea of the anus and rectum 
is very rare in women, and further asserts that direct contact 
of the pus with the deeper parts of the anal canal is necessary 
for infection. 

Gonorrhoea in the male is almost always the result of 
sodomistic practices and is therefore generally of the primary 
type. 

Dr. Zobel reported at the annual meeting of The Proc- 
tologic Society, June 7, 1909, three very interesting cases of 
primary gonorrhoea in the male, all of which resulted from 
sodomy. 

Symptoms. — At first there is heat and itching about the 
anus, which may appear from two to seven clays after exposure 
to the infection ; these symptoms are soon followed by acute 
pain, burning and tenesmus in the rectum, with frequent and 
painful defecation and with the passage of mucus and pus, 
which is sometimes tinged with blood. There is likely to be 
some rise of temperature. Upon inspection the mucous mem- 
brane is found to be bright red and swollen, and as the disease 
progresses patches of ulceration appear ; these are very super- 
ficial, with a granular base. After the disease has continued 
for some time the above symptoms are likely to be complicated 
with condylomata, fissure, and submucous fistulae. While the 
diagnosis in the early stages depends upon the presence of the 
gonococcus, Blake and Shuldham have called attention to the 
fact that " when gonorrhoea has reached its chronic stage, 
we may fail to find the diplococci, or true gonococci, but 



ULCERATIONS, SIMPLE AND SPECIFIC 139 

encounter instead pseudogonococci, staphylococci, streptococci, 
or tubercle bacilli." When such is the case, we have to rely 
on general symptoms, the history, and the exclusion of other 
similar inflammatory conditions, as, for instance, the absence 
of tubercle bacilli. 

Prognosis. — While the condition is quite obstinate to treat 
after it has extended well up into the rectum, yet under prompt 
and efficient measures it will yield to treatment, except where 
there is tuberculosis or constitutional syphilis. 

Treatment. — Antiseptic solutions should be used often and 
freely, such as a solution of the bichloride of mercury, I to 
ioooo; solutions of nitrate of silver, % to y 2 of I per cent.; 
or solutions of argyrol and permanganate of potash, any of 
which will rapidly destroy the gonococci. They should be 
used through a return-flow catheter, and irrigations should 
be repeated at least three times daily. If there are condylo- 
mata they may be clipped off, and the parts kept dry with a 
dusting-powder of boracic acid, calomel and bismuth. If 
there is a gonorrhceal vaginitis in the same subject, it should 
be treated by the same method, in order to prevent reinocula- 
tion. The irrigations should be continued for eight or ten 
days after the discharges cease. 

Chancroid of the Anus. — This form of ulceration is 
not uncommon among the lower classes, influenced very much 
by their uncleanly habits. It is much more frequent in women 
than in men, due to autoinoculation from the genitals, from 
probable contact with the diseased male organ, and the greater 
frequency of sodomy than of paederasty. This form of ulcera- 
tion is generally limited to the perianal region and the anal 
canal. 

Etiology. — It is not yet definitely settled whether the 
chancroid ulcer is due to simple pyogenic organisms, or to a 
specific germ. Where the ulcers appear on the surface around 
the anus, they are likely to be very superficial and have very 
few characteristics of a chancroid. When they exist in the 
anal canal they resemble a fissure very much, especially in 



140 DISEASES OF ANUS, RECTUM, AND SIGMOID 

the amount of pain accompanying them ; they are distinguished 
from fissure by frequently being multiple, bright red in color, 
secreting a large amount of pus, and being frequently sec- 
ondary to chancroids of the genital organs. 

Treatment.- — Frequent irrigations with antiseptic solutions, 
especially a solution of formalin, ]/ 2 dram to i pint, and the 
sore should be dusted with equal parts of calomel and oxide 
of zinc. If the pain continues it will be well to resort to 
forcible dilatation of the sphincter, or to incise it on either 
side and dissect out the scar tissue. After this is done, we 
should continue the antiseptic irrigations and the dusting- 
powders, keeping the evacuations soft and regular. 

Chancroidal Ulceration of the Rectum. — This is 
very rare and is generally the result of sodomy, or paederasty. 
The phagedenic variety, with its persistent tendency to spread, 
is more likely to extend from the anal orifice up into the 
rectum. 

Symptoms. — The symptoms of chancroid of the rectum 
are similar to those of simple ulceration, namely, diarrhoea, 
tenesmus, pain, and a profuse discharge of pus, tinged with 
blood. The ulcers are irregular in shape, with ragged borders, 
and grayish in color. Any chancroid may assume a phage- 
denic type, due to constitutional conditions. 

Treatment. — This is likewise similar to that for simple 
ulceration, except that more stimulating applications are 
required, and when there is a tendency to spread pure carbolic 
acid or the actual cautery should be applied to the ulcer. 
When the chancroid assumes a phagedenic type, in addition to 
the local applications recommended above, the patient should 
be well supported by a nourishing diet, stimulants, and good 
tonics. 

Complications. — A chancroid of the anus or rectum may be 
complicated with a true Hunterian chancre in the same lesion, 
or the chancroid may exist in connection with secondary 
syphilis. The physician should be careful, however, not to 



ULCERATIONS, SIMPLE AND SPECIFIC 



141 



confound syphilitic ulcers and broken-down mucous patches 
with chancroids. Subtegumentary fistulas are also likely to 
complicate chancroids, and when they exist they should be 
freely opened and cauterized. 

Syphilitic Ulceration. — This highly infectious form of 
ulceration may show itself in the skin around the anus, in 
the anal canal, or in the rectum, either as primary, secondary, 
or tertiary lesions. The primary lesion, which is always a 
chancre, may appear in or around the anus, or in the rectum, 
is more frequently met with than has been supposed, and is 




Fig. 44. — Spirochaete pallida from anal condyloma. (Sir Charles Ball's "The Rectum.") 
SP, Spirochaete pallida; SPP, Spirochaete pseudo- pallida; L, leucocyte; R, red blood 
corpuscle; B, bacillus; M, micrococci. (Drawn with camera lucida from smear preparation 
Teishman's stain, by Dr. H. J. Wright, I. M.S. House Surgeon, Sir Patrick Dun's Hospital.) 



much more frequent in women than in men. Wherever it 
may appear, its pathognomonic characteristic is the induration 
of its base, which is not very pronounced before the expiration 
of ten days or two weeks. The differential diagnosis may be 
made before this, by finding the Spirochceta pallida (Fig. 44). 
A simple hard chancre may also assume a phagedenic type. 
When the chancre is located in the anal canal, or on the sur- 
rounding skin, the inguinal glands on both sides become 
enlarged. A patient may have a true chancre without having 
any secondary symptoms, or they may be so slight as to pass 



142 DISEASES OF ANUS, RECTUM, AND SIGMOID 

unnoticed, yet they may show tertiary symptoms years after. 
These cases indicate that the systemic resistance at the time 
was sufficient to hold in abeyance the virus of the disease, 
but the seed of constitutional infection remained latent and 
at some period of depressed vitality overcame the resistance 
and developed with great intensity. 

Chancre of the rectum is very rare, and its existence is 
very positive evidence of the practice of sodomy, although it 
mav be possible for the infection to be carried into the rectum 
by the nozzle of a syringe or some such means. The symp- 
toms are similar to those of simple ulcer of the rectum, and 
the treatment is the same. 

Secondary manifestations of syphilis show themselves on 
the skin surface around the anal margin, in the form of mucous 
patches, which are merely transformed macular, moist papules, 
due to the moisture and continued contact of the parts causing 
the skin to break and the exposed raw surface to ulcerate. 
These papules may be single, but are generally multiple, and 
the secretion from them is very fetid and irritating. Mucous 
patches are rare within the rectum, but not so rare as is gen- 
erally believed. 

Secondary Ulceration of the Anus and Rectum. — It 
is difficult to draw the line between secondary and tertiary 
ulcerations of the anus. Lesions ordinarily considered to be 
secondary may make their appearance years after the primary 
sore. In such a case an ordinary abrasion may take on the 
characteristics of syphilitic ulceration. These ulcerations are 
by far the most frequent manifestations of syphilis that occur 
above the anorectal line. They occur as crater-like ulcers, 
single or multiple, with clean-cut indurated edges ; they rarely 
extend deeper than the submucous tissue in the early stages ; 
subsequently they may become very extensive and be attended 
with great destruction of tissue. The sacral glands become 
enlarged and the walls of the rectum beneath the ulcers feel 
leathery and indurated. The odor is fetid and disgusting, 
but very distinct from the discharge attending carcinoma. 



ULCERATIONS, SIMPLE AND SPECIFIC 143 

From the irritation and infection of these discharges there may 
be developed extensive ulceration about the anus. Even though 
these ulcerations may have reached a very destructive stage, 
they may be induced to heal by careful local and general treat- 
ment, but they are almost sure to be followed by stricture of 
the rectum, due to fibrous infiltration that always attends this 
form of ulceration. 

Treatment. — This consists of cleanliness, good drainage 
(which must be secured even at the expense of forcible dilata- 
tion or incision of the sphincter, and by keeping in a drainage 
tube), local antiseptic applications, and the administration of 
mercury. 

Tertiary Lesions. — These are principally gummata, 
destructive ulceration, anorectal syphiloma, and proliferating 
proctitis. The following are some of the characteristics of 
these tertiary lesions of the rectum that should be borne in 
mind, namely : They develop at no regular time after the 
initial lesion, and may never appear at all; they are likely to 
recur; they involve the deeper tissues, are destructive, upon 
healing leave cicatrices, do not yield readily to mercury, are 
very contagious, and are nearly always autoinoculable, show- 
ing that they are clue to a mixed infection. 

Gummata. — When these occur in the rectum, it is as a 
round, elastic and painless deposit in the submucous tissues; 
later they may involve both the mucous and muscular walls of 
the gut, and may be either single or multiple. If they do not 
break down and ulcerate, they do not produce any permanent 
stricture of the rectum. 

One of the most frequent manifestations of tertiary syphilis 
about the anus is a dry, brittle condition of the mucocutaneous 
tissue. It is similar in appearance to the condition of the 
same parts that attends atrophic catarrh. 

Destructive Tertiary Ulcerations. — These result from 
traumatism, disintegrating gummata, and necrosis of tissue, 
due to endarteritis obliterans. 



144 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Anorectal Syphiloma of Fournier. — Fournier (Lesions 
tertiaries de l'anus et rectum, Paris, 1875) describes under 
the above heading a specific fibrous infiltration of the rectal 
walls. He states that it is a hyperplastic proctitis, with a 
tendency to sclerotic change, as is seen in the kidneys and 
other organs in late syphilis. It begins in the submucous tissue. 

Proliferating Proctitis. — Paul Hamonic has described 
what he considers a peculiar syphilid, under the title of " Rec- 
titis Proliferante Syphilitique " (Anual Med. Chir. Trans. 
France et etrang., 1886, Vol. ii, page 31). It consists of a 
growth of fragile villose prolongations, of feeble resistance, 
from the mucous membrane of the rectum. Kelsey and Tuttle 
have each reported cases of this character. 

Treatment — The treatment of tertiary forms of syphilis 
of the anus and rectum consists in the administration of the 
iodides and the use of mercury by inunctions, or hypoder- 
mically, and by the local use of antiseptic washes and dusting- 
powders composed largely of calomel. After the ulcerations 
have healed rectal bougies should be introduced every alter- 
nate day to prevent contraction. 

Congenital Syphilis of the Anus and Rectum. — The 
appearance of this form of this disease in this locality is 
among its earliest manifestations, and may occur at any time 
after birth up to several years of age. It appears first as 
erythema around the anal margin; the skin is at first slightly 
pigmented, red, or copper-colored, but soon becomes thickened 
and elevated, after which a seropurulent fetid discharge 
exudes from it. 

Under the influence of cleanliness, with antiseptic washes 
and powders, this discharge is soon checked, but the diseased 
skin and mucous membrane becomes very friable, and shallow 
fissures make their appearance between the anal folds. Other 
symptoms will soon make their appearance, but the above are 
so typical that one need not wait for the appearance of these 
subsequent symptoms before instituting antisyphilitic treat- 
ment, which would do little if any harm to the child though 



ULCERATIONS, SIMPLE AND SPECIFIC 145 

the diagnosis of syphilis might be wrong. Gummata may also 
exist as a congenital symptom of syphilis of the rectum. Not- 
withstanding the fact that the majority of cases of syphilis 
in the new-born are hereditary, one should always bear in 
mind the possibility of its being acquired. 

Treatment. — The iodides with cod-liver oil and mercury 
by inunctions. The local treatment consists in the use of anti- 
septic washes, with a dusting-powder composed of equal parts 
of calomel and talcum powder N. F. 

Diphtheritic Ulceration. — A diphtheritic ulceration 
of the rectum has occasionally been noticed in connection with 
its existence in the usual location of the body, as in the naso- 
pharynx, and must be differentiated from membranous proc- 
titis by the presence of the Loffler bacillus in the former. 

Sir Charles Ball in his work on " The Rectum " (page 
6y) says : ''As far as I know primary diphtheria of the 
rectum has not as yet been demonstrated bacteriologically." 

Ulceration of the Rectum Due to Bilharzia Haematobia. — 
Frank Milton, M.R.C.S., Surgeon to the Kasr-el-Ainy Hos- 
pital, Cairo, delivered three lectures on this important disease, 
which appeared in The Journal of Tropical Medicine, 1902, 
Vol. v, pages 165, 191, 200, 213. He says that "the disease 
which is spoken of as bilharzia, and the chief symptoms of 
which are manifested through changes in the bladder and large 
intestine, is due to the deposition in the tissues of the eggs of 
a trematode worm, the Bilharzia hsematobia, whose favorite 
habitat is the portal vein." 

Mode of Infection. — It is almost certain that water is 
the vehicle, and that infection is brought about by drinking, 
and by no other means. By far the commonest seat of " bil- 
harzia " is the urinary bladder, and next in frequency of 
occurrence is in the rectum. 

At the beginning of the disease we must, of course, have 
had bilharzia worms introduced into the body of the host, 
where they have established themselves and set to work to 
10 



146 DISEASES OF ANUS, RECTUM, AND SIGMOID 

produce their eggs. The period of life and sexual activity of 
the bilharzia worm is not known, but it is probably of consid- 
erable duration, for cases have been recorded of patients who 
have ceased to inhabit countries where bilharzia is known to 
exist continuing to pass living eggs after years of residence 
under circumstances where reinfection would appear to be 
an impossibility. The eggs are 0.16 mm. in length and 0.06 
mm. in breadth. They have a smooth surface and are readily 
recognized by their possessing a spine situated as a rule at 
one end, but which under certain conditions may be placed 
laterally, this latter occurring frequently in eggs deposited in 
the rectum, while the eggs recovered from the bladder invari- 
ably have their spine at the end. The eggs when laid by the 
female bilharzia are free in the blood-vessels and drift until 
they are arrested in some capillary whose calibre is too small 
to let them pass ; this would seem to imply drifting against 
the current of the blood, as the eggs are produced in the veins 
where, of course, the current of blood is from small to larger. 
But I may perhaps be allowed to speak of drifting in the 
absence of any certain knowledge of how the eggs get from 
their point of origin in the larger veins to the smallest capil- 
laries. That they do get there is certain, and that they do not 
make the circuit of the systemic circulation is also certain, 
and we must be satisfied with these two facts. 

Mode of Exit. — As the life of the embryo has to be passed 
outside of the body of the host of the parent worm, nature 
directs the eggs towards the nearest point of exit from the 
body, and this will be the nearest surface from which they 
may be discharged ; this is the mucous membrane of the bladder 
and rectum. As more and more of these eggs find their way 
into the capillaries, which are already obstructed by the earlier 
arrivals, areas are formed in which the eggs are found closely 
packed together and not only plugging the minute vessels but 
many will have made their way through the coats of the 
latter and lie in the surrounding tissue. These deposits of 
eggs, when they have increased in size sufficiently to be visible 



ULCERATIONS, SIMPLE AND SPECIFIC 147 

to the naked eye, will appear as small pellucid bodies situated 
in the mucous membrane and raising its surface above the 
surrounding level. As these patches increase in size they 
coalesce with neighboring patches, until the whole mucous 
membrane becomes involved. As the patches increase in size 
they also increase in thickness, owing to the overgrowth of 
the surrounding tissue due to the irritation of the presence of 
the eggs, and also to the fact that nature striving to undo 
the mischief she has permitted for the sake of the propagation 
of the bilharzia species, tries to render the eggs harmless 
within the host by enveloping them in fibrous tissue and iso- 
lating them, as she does to foreign bodies imbedded in living 
tissue elsewhere. These two> processes, the irritative over- 
growth of the normal tissue and the formation of a new 
fibrous tissue, give rise to the formation of extensive raised 
patches of a yellow gray or brownish tinge with a granulated 
surface and of hard consistence, whose feel when explored by 
a sound soon becomes familiar and which is always pathogno- 
monic of bilharzia. These patches when they have attained a 
certain age begin to lose their vitality, partly by mechanical 
interference with their circulation and partly by the contrac- 
tion of the new fibrous tissue, and as a result they begin to 
break down and even to slough, giving rise to ulcers and 
crevices on their surface. This condition is frequently attended 
with great overgrowth of the normal structure of the mucous 
membrane, with formation of villosities, polypoid growths of 
great vascularity, and more solid coxcomb-like tumors, which 
are all equally typical of the disease (Sir Charles Ball, "The 
Rectum," Figs. 107, 108). These growths, although they are 
very plentifully supplied with blood-vessels, are all liable to 
necrosis and ulceration from blocking of their capillaries by 
the bilharzia eggs with which they swarm, and their disintegra- 
tion, as well as that of the thickened patches, gives rise to the 
discharge of blood, pus, minute sloughs, and bilharzia eggs 
entangled in mucus. It has been stated that mature worms 
have been found in dilatation of the veins in these polypoid 



148 DISEASES OF ANUS, RECTUM, AND SIGMOID 

growths, which would account for the enormous quantities of 
eggs and great overgrowth of tissue which occur in these 
cases. 

As might be expected the lower end of the intestinal tract, 
surrounded by a large plexus of veins (which are connected 
directly with the portal vein, in which the worms are most 
commonly found) and affording all the conditions which would 
appear most desirable to the adult bilharzial worm, is very 
commonly the seat of its activities. 

The excessive overgrowth in the normal structure in the 
mucous and submucous coats of the bowels previously spoken 
of, and which takes the form of polypoid adenomatous tumors, 
resembles somewhat ordinary hemorrhoids when the tumors 
appear near the anus, but within the gut and especially beyond 
the internal sphincter they differ materially from these latter. 
In the first place, in a given area they are infinitely more 
numerous than piles ever are, and instead of being rounded 
and smooth like hemorrhoids their surface is velvety from 
thickening of the mucous membrane itself, and their outline 
is broken up in all directions by the formation of secondary 
polypi, growing from their own surface and branching in all 
directions, until the large and fully-developed tumors bear a 
great resemblance to red branching coral. These tumors 
extend high up the rectum, beyond the reach of the finger, and 
this is so invariably the case that it would almost suggest the 
idea that the infection of the rectum begins from above in 
the neighborhood of the sigmoid flexure and proceeds down- 
ward; a possibility which has a most important bearing on 
the treatment, as will be seen later on. The infection of other 
parts of the digestive system, such as the liver, and conse- 
quently the production of sclerosis of that organ, does not 
concern us as rectal surgeons, although there have been sug- 
gestions of the possibility of a connection between bilharzial 
infection of the liver and hepatic abscess. But until now the 
connection has never presented itself formally to me, and I 
think for the present we may allow the question to stand over. 



ULCERATIONS, SIMPLE AND SPECIFIC 149 

Symptoms. — The symptoms are similar to those of other 
forms of ulceration of the rectum and sigmoid, namely, pain 
in the back and lower limbs, tenesmus, frequent stools, the 
passage of mucus, blood, and pus, which contain quantities of 
bilharzia eggs. 

Carcinoma and Bilharzia. — Besides the fibrous growth 
occurring in bad bilharzia cases, true carcinoma is also some- 
times found grafted on the existing disease, probably beginning 
in an irritative overgrowth of the glandular elements of the 
mucous membrane. This coexistence of carcinoma and bil- 
harzia is generally regarded as fairly common, but I do not 
think it does in reality occur so frequently as some writers 
would lead one to expect. The formation of what may be 
termed bilharzial tissue has probably been mistaken for cancer. 

Treatment. — The treatment of bilharzia of the rectum in 
its early stages consists in allaying the irritation of the parts 
and lessening as far as possible the hypersemia and secretion 
of mucus. Similar means are used for this purpose as in 
other forms of ulceration of the bowel, and with much less 
hope of permanent results, inasmuch as the exciting cause 
comes from within and is protected by the layer of tissue over 
them, so that it is impossible to obtain satisfactory results 
from antiseptics or germicides without doing permanent injury 
to the overlying tissues. 

While Dr. Milton mentions a number of palliative meas- 
ures, he closes the subject of treatment with the following 
sentence : " The disease will never be capable of true cure 
until we find some method of attacking the parent worms in 
their at present inaccessible habitation." 

Actinomycosis. — This is exceedingly rare in the region 
of the rectum. It may either have its primary seat in the 
rectum or in the perirectal tissues. It begins with the forma- 
tion of nodular granulomatous deposits in the mucous and 
submucous coats of the rectum; these contain the specific 
fungi, which break down and ulcerate. The ulceration may 
extend until it causes perforation of the rectum. The pathog- 



150 DISEASES OF ANUS, RECTUM, AND SIGMOID 

nomonic signs are the yellowish granules in the pus when 
present and the presence of the ray-fungus. 

Gangrene of the Rectum. — The more aggravated forms 
of any of these ulcerations under certain conditions are liable 
to be followed by gangrene; a condition rare in this locality, 
on account of its unusual blood-supply. 

Thrombotic gangrene is probably the most frequent form 
in which it occurs here, on account of the great liability of 
these vessels to become thrombosed, although the diabetic 
form may be expected here as elsewhere in cases of diabetes. 
It almost always proves fatal, and is the most infectious of all 
diseases of the rectum. 

M. Guibe in a very exhaustive paper published in The 
Revue de Chirurgie, 1908, reports in full a very interesting 
case of apparent " Spontaneous Gangrene of the Rectum." 
He reports also five cases of gangrene of which complete 
records were kept, and four cases in which the records were 
not kept. According to this authority gangrene is found 
almost exclusively in women. 

The pain attending gangrene is very intense, the discharge 
is excessive and very offensive and is rapidly followed by 
general sepsis; collapse and death is sure to follow in a very 
short time, in spite of all treatment. It resembles somewhat 
tubercular ulceration in the early stages. No specific organ- 
ism has yet been discovered as the etiological factor, but it 
rather seems to result from ordinary pus organisms, plus a 
lowered vitality, due principally to a defective blood-supply. 



CHAPTER VI 

PERIANAL AND PERIRECTAL ABSCESSES 

The tissues around the anal margin and in the rectum 
are subject to frequent abrasions, especially from hardened 
fecal masses, which are constantly exposed to infection from 
contact with the faeces. The parts having an abundant blood- 
supply with numerous lymph-vessels are peculiarly susceptible 
to inflammatory and suppurative processes. The character of 
the wound has little if anything to do with the extent of the 
infection. All that is necessary is a break in the skin or 
mucous surface ; the extent of the infection depends upon 
the character and virulence of the organism, and the resistance 
of the tissues. The excessive strain to which the blood-vessels 
of these parts are subjected by reason of the peculiar anatomic 
perforation of the muscular coat of the rectum, by the superior 
hemorrhoidal arteries, makes these veins especially susceptible 
to the rupture of their inner coat and consequent formation of 
thrombi ; these frequently are the foci of infection. Such in- 
fection may occur in any one of several ways : through small 
areas of pressure necrosis, through sebaceous glands, or hair- 
follicles. A certain number of other cases of infection of the 
deeper perirectal tissues can be explained by abrasions or 
perforations of the rectal wall by sharp-pointed foreign sub- 
stances in the faeces, which have either been taken in with the 
food or introduced into the rectum. There are also a large 
number of perirectal and pelvirectal abscesses in which the 
method of infection cannot be traced. Although infection 
travels along the course of lymphatic vessels as a rule, it can 
and does travel also along blood-vessels, hence with two 
such easy means of access to the deeper tissues it is not sur- 
prising that slight superficial abrasions on the skin or mucous 
membrane of these parts should be so frequently followed by 
infection and subsequent abscesses. 

151 



152 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Frequently it is not by any means possible to connect the 
primary source of infection (which may have healed in a few 
hours) with the abscess formation, which may not appear for 
several days. Let it be constantly borne in mind that these 
abscesses are not always primarily due to infection by the ordi- 
nary pus organisms, frequently originating for instance in an 
infection by tubercle bacilli, which, after advancing to the stage 
of caseation, may become infected with pus organisms second- 
arily and result in the formation of an abscess. Abscesses in 
these localities may also result from infection by the ordinary 
colon bacillus, whose normal habitat is the alimentary canal. 

The inflammatory processes which result in the formation 
of these abscesses may be either circumscribed or diffuse. 
Resulting in the formation of an enormous slough, it is said to 
be gangrenous. Then we have an erysipelatous form, which 
is very diffuse and spreads rapidly. Here is a very simple 
classification based principally upon the tissues involved : 

( Follicular 
Superficial j Subtegumentary 

( Ischiorectal 

( Retrorectal 
Deep J Superior pelvirectal 

( Interstitial 

Now recalling the anatomic divisions of the cellular spaces 
around the rectum, their separate blood and lymphatic supply, 
it is obvious why such distinction should be made in the cir- 
cumscribed inflammations in these respective localities. 

Follicular Abscesses. — These, due to direct infection by 
pathogenic organisms of the follicles or sebaceous glands of 
the skin around the anal margin, may develop as furuncles, 
some reaching a considerable size, attended with inflammation, 
swelling, pain, and suppuration ; sometimes assuming a graver 
type, involving subcutaneous and muscular tissues. As they 
do not generally involve the anal margin they are not likely to 
interfere with defecation, but are painful upon sitting or walk- 



PERIANAL AND PERIRECTAL ABSCESSES 153 

ing. Adjoining follicles are likely to become infected from 
the primary sore, giving rise to successive crops of these little 
furuncles. 

Treatment. — In opening the abscess, care should be taken 
not to extend the incision through the indurated base, which 
is Nature's provision for limiting infection. Let the incision 
be limited to the size of the abscess cavity, and after thorough 
evacuation of pus swab out with pure carbolic acid. To 
prevent recurrence of these little abscesses frequently bathe 
the wound and the surrounding parts with antiseptic solutions 
and dust the wound with calomel and boracic acid in equal 
parts. 

Subtegumentary Abscesses. — These always result from 
infection received through an abrasion of the skin or mucous 
membrane. Infection is taken by the lymphatics to the deeper 
tissues, where it is arrested either in a gland or by a thrombus 
in a lymphatic trunk, which then becomes the focus of infec- 
tion and the seat of the abscess. Frequently such abscesses 
follow the infection of a thrombotic hemorrhoid. 

Symptoms. — The first symptom that is likely to attract the 
patient's attention is pain, at first dull and throbbing in char- 
acter; its severity seeming to depend in a measure on the 
proximity of the inflammatory process to the sphincter muscle 
and the anal canal, where the tissues are more closely attached 
and there is greater resistance. This is soon followed by swell- 
ing, varying in amount with the extent of the inflammatory 
process and the amount of tissue covering it. Many of these 
abscesses have ruptured before the patient seeks the advice of 
a physician, and in such cases the opening is nearly always 
internal, generally in the anal canal, this being the direction 
of least resistance. It is surprising to what extent burrowing 
has taken place even in those cases where only a few days 
have elapsed since the abscess formation, nor will rupture of 
abscess cavities stay this burrowing if the vent does not drain 
the cavity freely ; hence the necessity for enlarging such an 
opening, or substituting another in a more dependent position, 



154 DISEASES OF ANUS, RECTUM, AND SIGMOID 

as soon as the case is seen. If the abscess develops around the 
upper portion of the anal canal, there will be little evidence of 
the swelling externally, and it will best be appreciated by the 
introduction of the finger in the anal canal while pressure is 
made against the buttocks with the thumb of the same hand; 
in these cases the pain is likely to be very acute. Spontaneous 
opening most frequently occurs in the anal canal, and forms 
the typical case of blind internal fistulse ; the opening in these 
cases is usually higher than the bottom of the abscess cavity, 
which is therefore only imperfectly drained, and the retained 
pus soon burrows and points on the buttocks or perinseum. 



iy 


f/$ 




yfj 




iiir-"ii 




Iff 




ifcfc 




ii 


c| 








S.'IG 









Fig. 45. — Showing the location of superficial and deep abscesses around the anus and 
rectum. A, intramural, or submucous abscess; B, retrorectal abscess; C, ischiorectal 



If large, these abscesses are likely to be attended with some 
constitutional symptoms, such as rise of temperature, etc. 

These abscesses generally result in formation of fistulas, 
with contraction, but not in an obliteration of the abscess 
cavity, and refuse obstinately to heal without surgical inter- 
ference. No satisfactory explanation has ever been given; 
the most rational one is that generally if not always there is 
an internal opening into the rectum, through which the tract is 
constantly reinfected, preventing its healing. In a certain 
number of cases the abscess may form above the internal 
sphincter in the submucous tissue of the rectal wall, forming 
an intramural abscess (Fig. 45, A) recognized by its boggy feel, 



PERIANAL AND PERIRECTAL ABSCESSES 155 

and distinguished from an inflamed internal hemorrhoid by 
being beneath the surface and not projecting as much into 
the lumen of the bowel. 

Treatment. — Whenever a subtegumentary or a submucous 
abscess is met with in the region of anus, anal canal, or rectum, 
it should be opened immediately and freely, whether the usual 
indications of pus exist or not. If pus has not formed, an 
incision relieves congestion, lessens tension and directs the 
pus, when it does form, to the surface. For a swelling due to 
extravasated blood, incision is still demanded in order to turn 
out the blood clot. If pus has already formed, prompt evacu- 
ation is the only safeguard against its burrowing; and if done 
before connection has been made with the interior of the 
rectum, it may prevent the formation of a fistula. In the 
case of an intramural abscess, open freely from the mucous 
surface of the rectum, swab out the abscess cavity with pure 
carbolic acid, let the sphincter be stretched, and frequent irri- 
gations of antiseptic solutions used. In opening a subtegu- 
mentary abscess make the skin incision in the line of the 
radial folds ; it should be free, and extend to the limits of 
the abscess cavity. If the abscess be opened soon -after forma- 
tion, it will not require curetting, but all pus should be pressed 
out of the cavity, which should then be swabbed with dry 
cotton and afterwards with pure carbolic acid. Subsequent 
treatment consists in thorough drainage, irrigations with anti- 
septic solutions, and cleanliness. 

Ischiorectal Abscesses. — These occur in the ischiorectal 
fossae and are a typical form of what is known as perirectal 
abscesses (45, C). Outside the muscular and aponeurotic layers 
of the rectum, and beneath the skin and superficial fascia, they 
may be limited to one side of the rectum, or occur on both 
sides simultaneously, or successively, and are connected pos- 
teriorly through the little space existing between the aponeuro- 
sis of the levator ani and the external sphincter muscle. When 
opened they do not exhibit a single large abscess cavity, but 
numerous foci of pus. This honeycombed condition is due to 



156 DISEASES OF ANUS, RECTUM, AND SIGMOID 

the connective-tissue network which divides the cellular tissue 
into spaces, and in operating, unless great care is exercised to 
open up all these, the pus contained in them will burrow and 
infect other regions. Where these abscesses exist in both fossae, 
and communicate with each other posteriorly through the 
foramen already mentioned, there will be found generally an 
opening from the communicating sinus posteriorly into the 
rectum at the posterior commissure ; this opening into the 
rectum has frequently been the primary source of infection 
for both fossae. Pus from an ischiorectal abscess may burrow 
through the levator ani muscle and infect the retrorectal space 
(Fig. 45, B), but is not likely to extend from the ischiorectal 
fossae to the pelvirectal space, as the pus would have to burrow 
against gravity, a rare thing, unless tension is very great. 
The reverse condition, however, — infection of the ischiorectal 
fossa by pus from the pelvirectal space, — is very likely to occur, 
for frequently the subcutaneous tissue around the anus and the 
submucous cellular tissue around the anal canal become in- 
fected from the pus from a pelvirectal abscess. 

The importance of these suggestions and possibilities show 
the necessity for the early evacuation of pus, to prevent its 
extension to these different spaces and thus becoming more 
serious. 

Symptoms. — There is redness, swelling, and pain, and, as 
these abscesses are generally large, the formation of pus is 
likely to be attended with constitutional symptoms, such as 
distinct rigor, rise of temperature, accelerated pulse, and head- 
ache. The induration can generally be felt before the swelling 
and redness are apparent to the eye. The inflammatory process 
may be very extensive and involve the perinaeum, anus, rectum, 
scrotum, and both buttocks, but such an extensive involvement 
is only likely to follow delay in opening the abscess cavity. 
imperfect drainage, or very virulent forms of infection. If 
there has been much delay, the pus is likely to be very fetid 
and of a disgusting odor, not due, as often supposed, to any 
direct connection of the abscess with the rectum, but most 



PERIANAL AND PERIRECTAL ABSCESSES 157 

likely to the character of one of the pus-forming organisms 
common in this locality. The same may be said of the gas 
which sometimes escapes with the pus. 

All the physical conditions and local symptoms of an ischio- 
rectal abscess may result from a hemorrhage into the spaces, 
without the extravasated blood becoming infected. This 
may be suspected if these local conditions appear without the 
constitutional symptoms of inflammation, or it may be a sub- 
acute tubercular process. 

Treatment. — A free incision should always be made at the 
earliest possible moment, even at the risk of anticipating the 
formation of pus. This may be done under the influence of 
local anaesthesia by J / 2 of i per cent, solution of cocain, if the 
abscess is sufficiently deep to allow the injection to be made 
in the healthy tissues above it. Let the incision be wider than 
the abscess cavity, so as to furnish free drainage, and well 
outside the sphincter muscle ; the finger is now introduced into 
the cavity, the trabecular of necrotic tissue broken down and 
the necrotic surfaces scraped lightly with a dull curette, then 
swabbed with a solution of pure carbolic acid, and if there is 
much oozing of blood it may be packed with, gauze for the 
first tw r enty-four hours. Subsequent treatment consists in 
keeping the wound well drained, if necessary with rubber tub- 
ing or strips of gauze ; frequent irrigations with antiseptic 
solutions, and applications of a 5 per cent, solution of nitrate 
of silver to the raw surface every alternate day. Where the 
abscess involves both ischiorectal fossae, the incision should be 
very free on one side and extend up to and include the pos- 
terior commissure ; the incision into the other fossa need only 
be sufficiently large to drain it thoroughly. If no opening into 
the rectum can be found, it will be better to stretch the sphincter 
muscle, as this relieves the muscular spasm, allows gas and 
faeces to come away freely, and thus relieves the thin rectal 
wall of any undue pressure. For the same reason it is better 
to leave in the rectum a piece of stout rubber tubing after 
stretching the sphincter. 



158 DISEASES OF ANUS, RECTUM, AND SIGMOID 

DEEP ABSCESSES 

The distinction between superficial and deep abscesses is 
that the former occur in the tissues below the levator ani 
muscle and the latter above it. There are three spaces that 
exist above the levator ani muscle around the rectum. The 
two lateral ones have been designated by Richet " the superior 
pelvirectal spaces " ; as previously described in the anatomy of 
the rectum, the posterior is " the retrorectal space." The 
latter occupies all the region between the rectum and the 
anterior surfaces of the sacrum and the coccyx. 

The blood-vessels which ramify in the retrorectal space 
come from the middle and lateral sacral arteries, with a few 
branches from the inferior mesenteric. Those in the superior 
pelvirectal space come from the hypogastric artery and are 
connected with the general circulation. The lymphatics of 
the two spaces are also comparatively distinct. With such 
distinct anatomic divisions, vascular supply, and lymphatic dis- 
tribution, it is readily understood why a distinction is made 
between the circumscribed inflammations in these two areas. 

Retrorectal Abscess. — This develops from an infection in 
the cellular tissue of the retrorectal space, frequently follow T - 
ing the operation of posterior proctotomy for stricture of the 
rectum, especially where there has been imperfect drainage 
(Fig. 45b). This space may also be infected by the fistulous 
tracts which often form in connection with strictures ; from 
the breaking down of gumma, or tuberculous glands; from 
extension from ischiorectal abscesses, or varicose ulceration ; 
and often follow resection of the rectum. 

Symptoms. — Apart from the usual symptoms attending the 
formation of deep-seated abscesses around the rectum, such as 
a dull heavy pain in the sacrum, with a sense of weight in the 
pelvis, and shooting pains down the course of the sciatic nerve, 
the special symptoms are rather obscure in the early stages. 
There is likely to be an increase of pain attending defecation, 
and some rise of temperature. 



PERIANAL AND PERIRECTAL ABSCESSES 159 

Upon introducing the finger into the rectum a boggy mass 
can generally be felt posteriorly in the hollow of the sacrum. 
If not punctured early, the abscess will either rupture spon- 
taneously into the rectum, or perforate the levator ani muscle, 
infect the ischiorectal fossa, and finally open on the skin of the 
buttocks. When the latter does occur, or whenever the abscess 
invades any of the superficial tissues around the anus it will 
likely be attended with constitutional symptoms and very 
severe pain. These abscesses may also burrow outward 
through the ischiatic notch and open on the buttocks. 

Treatment. — A free and deep incision in the shape of a 
quadrant should be made in the skin between the anus and 
coccyx. After the abscess cavity has been evacuated it should 
be gently scraped with a dull curette and irrigated with a 
solution of bichloride of mercury i to iooo. A rubber drain- 
age-tube may then be introduced and held in position for 
several days to promote thorough drainage and the sphincter 
moderately dilated to allay spasm. Subsequent treatment 
consists in irrigating the cavity twice a day with an anti- 
septic solution occasionally stimulating the granulations with 
from 5 to 10 per cent, solutions of nitrate of silver, and allow- 
ing the patient to walk about the day following the operation, 
to facilitate drainage. 

Superior Pelvirectal Abscess. — The infection giving rise 
to these abscesses seldom comes from the rectum, but from 
adjoining organs and canals, as from posterior urethritis, a 
prostatitis, seminal vesiculitis, or from any of the infectious 
diseases peculiar to the generative organs. When it occurs in 
women it is spoken of as a pelvic abscess. The superior pelvi- 
rectal spaces may also become infected from a psoas abscess, 
an appendicitis, necrosis of the bones of the pelvis, or from 
an infection of the anterior rectal wall, the infection being 
carried by the middle lymphatics and arrested in the lower part 
of these spaces by the sudden bending of the lymphatic vessels. 

Symptoms. — The primary symptoms are generally referred 
to the organ or canal in which they arise. The condition is 



160 DISEASES OF ANUS, RECTUM, AND SIGMOID 

frequently ushered in by a chill, fever, uneasiness, and pain, 
usually situated in the neck of the bladder, and there is almost 
invariably frequent and painful micturition. There may be 
complete obstruction of the urine from pressure on the ureters, 
oedema of the scrotum, or vulva, with pains in the perinaeum. 
In the latter stages, when the accumulation of pus is consid- 
erable, there is likely to be difficulty and pain attending 
defecation. 

There is a tendency for the pus to burrow upward into 
the iliac fossa in these cases, rather than toward the perinaeum 
where there is great resistance ; hence there is considerable 
danger from the probability of the abscess rupturing into the 
peritoneal cavity, especially if its evacuation by surgical 
methods is delayed. The pus from these abscesses may also 
perforate the bladder, urethra, or rectum, but very rarely the 
vagina; they may also break through the levator ani muscle 
and invade the retrorectal or ischiorectal spaces. 

Diagnosis. — The history of the case is very important in 
making the diagnosis, as might be inferred from what has 
been said about the infection originating in adjoining organs. 
A digital examination of the rectum and vagina will give the 
most valuable information in making the diagnosis ; it will 
elicit tenderness, swelling, pain above the prostate in males, 
and to one or both sides of the central line, extending around 
the rectum. In women it is higher up, and more to the side.. 
In thin people the swelling may be more clearly outlined by 
bimanual palpation, introducing one finger into the rectum or 
vagina and the other hand pressing upon the lower part of the 
abdomen. 

Treatment. — This consists in the free evacuation of the 
pus at the earliest possible moment, by a free and wide incision, 
made to the side of the rectum in which the swelling is felt, 
about the posterior part of the anterior quadrant, parallel to 
the fibres of the external sphincter muscle, and at right angles 
to and through the fibres of the levator ani muscles. The 



PERIANAL AND PERIRECTAL ABSCESSES 161 

deeper part of the incision should be made by careful dissec- 
tion in order to avoid injuring important organs. The 
sphincter muscle should be stretched. After the abscess cavity 
has been thoroughly evacuated, a long drainage-tube should be 
introduced, after which irrigations with antiseptic solutions 
should be begun. 

Curetting of these cavities is advisable only in the hands 
of the most experienced. Packing, if done at all, should only 
be to control excessive oozing and the material not be allowed 
to remain in longer than twenty- four hours. If in the course 
of a few days the wound should seem sluggish and the dis- 
charge remain fetid, the cavity may be swabbed out with a 
95 per cent, solution of pure carbolic acid. In women, the 
abscesses are likely to become chronic, and coexist with chronic 
cellulitis. 

The pelvirectal, retrorectal and the ischiorectal spaces are 
subject to a very virulent form of septic infection from per- 
foration of the rectal wall in defective drainage. This is 
sometimes spoken of as a diffuse septic periproctitis, but the 
extent of the infection is only measured by the depth of the 
perforation, the resistance of the tissues, or the virulence of 
the organisms. The symptoms from such an infection are 
exactly similar to those previously described when either of 
these spaces is infected by ordinary pus organisms, except 
that in the former they are very much aggravated by the 
increased virulence of the organism and are much more likely 
to prove fatal, unless promptly checked. 

Idiopathic Gangrenous Periproctitis. — Under this title 
Furneaux Jordan (British Medical Journal, January 18, 1879, 
page 73) has described a very unusual type of perirectal 
inflammation. " It consists in a slowly extending cellulitis, 
which is not attended with much swelling, or pain. It develops 
usually without any previous injury, although it may follow 
surgical operations about the rectum. It resembles very much 
the condition produced by urinary infiltration of the perinseum. 
It occurs generally in high livers and drinkers, and so far all 
11 



162 DISEASES OF ANUS, RECTUM, AND SIGMOID 

the cases reported have been in males. Although quite a 
number of surgeons have reported individual cases of this 
disease, yet it is rather rare. 

" Etiology. — There is nothing definite known of its 
etiology, or pathology, no satisfactory study of its bacterio- 
logical factors having been made, so far as we are aware. 

" Symptoms. — The disease comes on with a chill, followed 
by high temperature, and great mental and physical depression. 
There is some pain about the anus, the skin is red and brawny, 
the epithelium elevated and covered with small vesicles; these 
soon break clown and leave black gangrenous patches, which 
discharge an ichorous fluid instead of pus. The disease extends 
very rapidly, and tends to recur and invade other tissues after 
it has apparently been checked. It invades all the deep spaces, 
and tends to progress upward toward the peritoneum, or, after 
invading the retrorectal space, it may pass out through the 
obturator foramen, and invade the subtegumentary tissues on 
the buttocks. Whenever the peritoneum becomes involved, 
death ensues very rapidly. Even if the patient does not suc- 
cumb to sepsis and exhaustion during the early stages of the 
disease, it will require the greatest amount of skill and good 
management to tide him over the more exhausting stages of 
sloughing and to increase the danger, probably hemorrhage. 

" Treatment. — Make free and repeated incisions through 
all gangrenous tissues, wherever they appear to be followed by 
frequent antiseptic irrigations and hot antiseptic poultices. 
If these incisions are followed by excessive hemorrhage, as 
likely, it is best controlled by pressure, the vessels being very 
friable in this condition. General stimulation, with the most 
nutritious and concentrated food is necessary." 

Interstitial Abscesses. — These occur in the muscular and 
cellular tissues of the buttocks, and are more or less remote 
from the rectum, the infection being carried from the peri- 
rectal tissues along the course of the lymphatics. The symp- 
toms and treatment are similar to those in the varieties pre- 
viously described, except that the pus is not so deep seated. 



CHAPTER VII 
FISSURE IN ANO, OR PAINFUL ULCER 

An anal fissure is a rather superficial elongated rent or 
crack, situated in the mucocutaneous tissues (Fig. 46), and 
characterized by acute pain and paroxysmal contraction of the 
sphincter muscle. The term fissure is generally but improperly 
applied to all forms of ulceration that are within the grasp of 
the sphincter muscle, many of which are wanting in the true 
characteristics of fissure in ano, namely, the peculiar pain 
and paroxysmal contraction of the sphincter. While these 
ulcers generally present the appearance of an elongated slit 
in the contracted state of the anal canal, if the latter is dilated 
the ulcer will frequently present an oval or circular appear- 
ance ; it is when they are so presented more or less irregularly 
in the contracted state of the anal canal that they are denom- 
inated ulcers. Ulcerations of the rectum which occur in the 
mucous or submucous tissues above the sphincter muscle, 
even though they encroach upon the upper limits of the said 
muscle, should not be classed as painful ulcer or fissure. 

Pathology. — I do not think it worth while to speak of the 
slight pathological changes found in the acute and superficial 
cases of fissure in ano which are wanting in the essential 
characteristics, and are merely characterized as such from their 
location and appearance. The characteristic features of fissure 
in ano are dependent upon pathological changes found in more 
chronic forms of this ulceration and now to be described. 
The edges of the ulcer are elevated, irregular, and thickened, 
and the tissues at the base of the ulcer infiltrated with fibrous 
tissue, which renders them hard and inelastic. According to 
the microscopic examinations of M. Hartman {Op. cit., page 
422), in the deep muscular layer the nerve-trunks are sur- 
rounded by fibrous material and show interstitial and intra- 

163 



164 DISEASES OF ANUS, RECTUM, AND SIGMOID 

fascicular neuritis. The sphincter muscle itself is hyper- 
trophied and very resisting. These characteristics may be 
found in any form of ulcer in this locality, and, on account of 
the symptoms which attend such pathological changes, would 
constitute a fissure in ano or painful ulcer, no matter what 
specific character might constitute its etiological factor. 




Fig. 46. — Fissure in ano. 



Earle's rectal speculum introduced; 
rhoid; C, fissure. 



B, ulcerated hemor- 



Etiology. — While the chief primary cause of fissure is 
constipation, due to tearing of the surfaces by hard fecal 
masses, yet it is only by frequent repetition of this accident 
in normal tissues that the requisite pathological conditions 
causing the train of symptoms found in fissure in ano are pro- 
duced. I am strongly of opinion that .fissure in ano is most 
frequently preceded by the necessary pathological conditions 



FISSURE IN ANO, OR PAINFUL ULCER 165 

induced by an inflamed tag, or some other subacute inflamma- 
tion of these parts, resulting in fibrous infiltration rendering 
it inelastic and unyielding, hence the frequent association of 
fissure with such a condition. 

Fissure in ano may also be produced by : foreign bodies, as 
spicula of bone or irritating substances in the faeces, produc- 
ing an abrasion and consequent ulcer ; congenital narrowing of 
the anus; foreign bodies introduced into the rectum; polyps 
which overhang and protrude into the anal canal at stool ; the 
different forms of specific ulceration, as syphilitic, tubercular, 
or malignant ; atrophic proctitis ; diseases of the skin involv- 
ing the anal margin ; occasionally from an operation on. the 
anal outlet where healing has been delayed by neglect or 
improper treatment ; pederasty ; tearing of the semilunar valves 
by the projection of some foreign substance in the faeces 
(Ball) ; and hemorrhoids are a very frequent cause. 

Spontaneous healing of these painful ulcers rarely if ever 
occurs, because of the pathological conditions already alluded 
to. 

Symptoms. — The most characteristic symptom is the pecu- 
liar pain and the length of time it continues after an evacuation 
of the bowel or from any distention of the sphincter muscle. 
As a rule the patient feels perfectly comfortable until he has 
a stool, nor in most cases does the pain immediately follow 
the stool, but comes on from fifteen to twenty minutes after- 
ward. At first it is only a dull aching soon increasing in 
severity until it becomes almost unbearable; this degree of 
severity is maintained for several hours, then gradually sub- 
sides, the patient getting fairly comfortable late in the day ; in 
other cases it may only last a few hours, to recur again at the 
next stool, after each of which, however, it is likely to grow 
more severe and be more protracted. 

There is frequently a small amount of blood lost at each 
stool, from a fresh tear in the old ulcer. The constipation 
which probably preceded the fissure is likely to be increased 



166 DISEASES OF ANUS, RECTUM, AND SIGMOID 

by the pain and spasm of the sphincter muscle which, attends 
each evacuation of the bowel. Quite a clear relationship exists 
between the character and severity of the pain, the chronicity 
of the fissure or ulcer and the extent of fibrous infiltration. 
The nearer the location of the ulcer to the anal margin, the 
more acute and severe the pain. 

Reflex Symptoms. — The most usual reflex symptoms asso- 
ciated with fissure in ano are painful micturition, pains in the 
back, neuralgic pains running down the legs, and sometimes 
occipital and facial neuralgia. 

Diagnosis. — While the peculiar character of the pain in 
the majority of cases of fissure in ano as heretofore described 
may indicate fairly well the character of the trouble, yet the 
only positive way of making a correct diagnosis is by careful 
inspection. When making such, the physician should be very 
careful not to cause any more pain than is necessary, remem- 
bering the exquisitely sensitive condition of the parts. The 
examination can generally be made sufficiently satisfactory 
without the aid of the speculum, or, when that is necessary, it 
will be sufficient to introduce it for" a very short distance only. 
With the buttocks well separated and the patient directed to 
Bear down, the fissure can generally be seen, especially if the 
usual tag of skin is present at the lower margin to direct the 
examiner. If this should fail, then an Earle rectal or a Sims 
vaginal (virgin size) speculum may be partially introduced 
into the anal canal, pressing the instrument against the oppo- 
site wall and pulling it away from the fissure. If this is done 
carefully and gently, just sufficiently to get a glimpse of the 
lower portion of the fissure, it will suffice to make a diagnosis 
of fissure, which is all that is necessary to warrant the use of 
a general anaesthetic for an operation, when a more careful 
examination of the rectum for additional trouble can be made. 
The best position for a patient to assume for this examination 
is the left lateral or Sims's. In women when the fissure is on 
the anterior anal wall a satisfactory view of it may be obtained 
by introducing the index finger in the vagina and turning the 



FISSURE IN ANO, OR PAINFUL ULCER 167 

anterior wall of the rectum out. If the fissure is very sensitive 
the pain may be allayed by the insufflation of powdered anes- 
thesine, which w T ill have the desired anaesthetic effect in a few 
minutes, as seen by the gradual relaxation of the sphincter 
and complete exposure of the fissure. 

Treatment. — Little need be said of the palliative treatment 
of chronic cases of fissure in ano, because even should it 
succeed in causing the fissure to heal, the scar tissue which 
exists at the base of the wound will tear again the first time the 
patient has a constipated stool. In acute cases, and in those 
who refuse to be operated upon, much comfort can be given 
by carrying out the following directions : Keep the fecal 
evacuations soft, restrict the patient to one stool in twenty- 
four hours, make him lie down for half an hour after the 
stool, and during that time, or as long as the pain continues, 
have him apply hot-water bags to the perinseum. To regulate 
the bowels give moderate doses, of the fl. ext. cascara sagrada, 
or of the fl. ext. senna, which may be assisted by enemas of 
cotton-seed oil, or warm water. If hemorrhoids coexist, an 
enema of cold water is better to relieve the congested hemor- 
rhoids. The diet should consist largely of fruit and vege- 
tables in order to encourage soft and mushy stools. To allay 
irritability of the sphincter, powdered anesthesine may be 
applied directly to the fissure. After letting it remain a few 
minutes in order to get its local ansesthetic effect, a pledget of 
cotton is soaked in pure ichthyol and applied to the fissure, 
which is exposed by the aid of an Earle speculum holding- 
back the opposite wall. These applications should be made 
daily. In acute cases these directions may relieve permanently. 

Operative Treatment. — The procedure for the treat- 
ment of fissure in ano includes forcible dilatation, incision, 
and excision. Probably the largest number of cases at the 
present day, if we except those by specialists in proctology. 
are treated by dilatation. As they are likely to keep in touch 
with their cases, and as recurrences from the hands of others 
are more prone to come under their care, they have been 



168 DISEASES OF ANUS, RECTUM, AND SIGMOID 

better able to judge of the frequent failures of this method, 
the cause of which is, that in forcible dilatation a rent is made 
through the bottom of the ulcer, which, while it gives imme- 
diate relief from the most distressing symptoms by putting 
the muscle at rest, leaves in situ the scar tissue, which tears 
again whenever the patient becomes constipated, and the whole 
train of distressing symptoms return. Such a failure is espe- 
cially likely to take place where there is a polypus at the upper 
angle of the fissure, unless the polypus is first removed, and 
the same may be said of the inflamed tag of skin that is some- 
times met with at the lower angle of the fissure. We would 
therefore advise that excision should supplant forcible dilata- 
tion in all cases of chronic fissure in ano. For its application 
in acute cases, and for the benefit of those who still wish to 
practise forcible dilatation here is the technic : 

It may be done either by introducing both thumbs into 
the rectum, using the tuberosities of the ischium or pubis and 
sacrum as a fulcrum to be clasped by the fingers toward which 
the sphincter is pulled ; or by introducing all four fingers in 
succession, then lapping them in such a manner as to form a 
cone; or by a mechanical dilator, probably the best and safest 
of which is a conical metallic dilator devised by Howard A. 
Kelly. Whichever method is used, care should be taken to 
proceed siowly and gently until the muscle is felt to yield under 
the pressure. Even with the greatest care and gentleness the 
floor of the fissure or ulcer is almost invariably torn through, 
and the good results in relieving pain are probably due more 
to this fact than to relaxation of the muscle brought about by 
stretching it. This is made more probable by the rapid return 
of the tone of the sphincter muscle after such forcible dilata- 
tion. Within an hour after the divulsion there is no gaping of 
the anal orifice, and the muscle will respond in a measure to 
stimulation. At the end of seventy-two hours sphincteric 
control will be almost complete. The dilatation is generally 
attended with some hemorrhage, but this is never alarming. 



FISSURE IN ANO, OR PAINFUL ULCER 169 

If paralysis of the sphincter muscle facilitates the healing 
of the fissure, and in view of what has just been said about 
the early return of muscular contraction following dilatation, 
it would doubtless be better to introduce the Lynch tube and 
let it remain for forty-eight hours. Those who have tried 
this think well of it, and assert the patient to be much more 
comfortable with the tube in. Permanent incontinence of 
faeces has been known to follow forcible dilatation of the anus. 
Of this result James P. Tuttle has reported two cases. 

Incision. — The second method for operating consists in 
incising the fissure or ulcer through its base. This was first 
advocated by Boyer in 1788, he claiming the fissure to be due 
to spasm of the sphincter and advising its complete division to 
control the spasmodic contraction ; he did not advocate cutting 
the muscle through the base of the ulcer in all cases, but some- 
times divided it on either side of the rectum. He also intro- 
duced a plug to keep up continuous dilatation. Subsequently 
others held that it was only necessary to divide the superficial 
muscular fibres directly beneath the ulcer. At present both 
depth and location of incision are considered of greatest impor- 
tance ; let it be deep enough to put the muscle at rest and 
made through the floor of the ulcer to avoid the risk of sec- 
ondary infection. These directions do not apply to ulcers 
directly over the anterior or posterior commissure. On 
account of their decussations at the former, and of their ten- 
dinous prolongation to unite with the coccyx at the latter, at 
either of these points the V-shaped incision is best. This 
puts the muscle on both sides of the fissure at rest. Make 
the incision a little longer than the fissure — quarter of 
an inch deeper than at its greatest depth — and squarely across 
the muscle fibres. Where no complications exist, the incision 
may be made under local anaesthesia by a hypodermic injec- 
tion of yi of 1 per cent, solution of cocain ; the injection being 
made directly beneath the floor and to the sides of the ulcer, 
taking care to use plenty, as there is little danger from such 
a weak solution. After making the injection and waiting for 



170 DISEASES OF ANUS, RECTUM, AND SIGMOID 

several minutes for its anaesthetic effect, introduce a single- 
bladed speculum against the opposite wall of the anal canal, 
which will bring the fissure into full view, when the length and 
depth of the incision can be watched. If there is a polypus or 
hemorrhoid at the upper angle, or a sentinel tag at the lower 
one, it should be excised ; the indurated edges of the ulcer 
also removed and granulations scraped off; then the incision 
packed lightly with sterile gauze and the patient confined to 
bed for twenty-four hours. 

Excision of the Fissure. — Reference has been made to the 
necessity of excising the scar tissue in the treatment of fissure 
in ano, and any method that fails to thoroughly accomplish 
this end will fail to give permanent relief. This can be 
properly given only by excision, therefore in all chronic cases, 
or whenever the scar tissue can be recognized, I would suggest 
it. The resulting wound may either be closed by catgut 
sutures, or allowed to heal by granulation ; I myself preferring 
the latter method, and if complications exist, they can be 
removed at the same time. My preference for allowing these 
wounds to heal by granulation is on account of the possibility 
of infection from the ulcer, and the extreme sensitiveness of 
the parts which always exists in connection with fissure; the 
closure of the wound by sutures is followed by a great deal 
of pain, which is likely to last as long as the tension of the 
sutures continues. If the wound is left to heal by granulation, 
it should be irrigated twice daily with a mild antiseptic solution. 

The Complications of Fissure. — The wound following 
an operation for fissure may become infected and give rise to 
infiltration of the tissues by pus, which may even form pockets. 
This condition must be met by securing better drainage, more 
frequent irrigations, and stronger antiseptic solutions. If 
the bowels are allowed to become constipated, especially if 
hard scybalous masses form before complete healing and 
tissues have regained normal elasticity, the wound is likely to 
be torn open. Special attention should, therefore, be paid to 



FISSURE IN ANO, OR PAINFUL ULCER 171 

keep the evacuations soft and regular. Should the fissure be 
tuberculous, then let the incision be made with the actual 
cautery knife. Incontinence of faeces may follow any of the 
operations for fissure; it generally results from an oblique 
incision of the sphincter muscle, which should always be 
avoided. When it follows forcible dilatation, it is generally 
due to too rapid or too great divulsion of the muscle, or to 
stretching it in very old or very feeble persons. 



CHAPTER VIII 
MALFORMATIONS OF ANUS AND RECTUM 

By referring to the embryology of the foetus it will be seen 
that the anus and rectum are developed from different layers 
of the blastoderm, and that the blood-supply of each is derived 
from different sources ; therefore they do not necessarily 
develop completely or simultaneously, and when they do not, 
malformations result. Such malformations of either anus or 
rectum are likely to be associated with malformations of other 
parts of the body derived from the corresponding layer of 
the blastoderm. 

The classification of these malformations is based upon the 
above-mentioned differences in origin. I class them under : 
malformations of anus and malformations of rectum. 

Malformations of Anus. — (a) Entire absence of anus 
(Fig. 47); (b) Abnormal narrowing; (c) Partial occlusion; 
(d) Absolute occlusion; (e) Anal opening at some abnormal 
point on the perinseum, scrotum, or sacrum (Figs. 48, 49). 

Malformations of the Rectum. — (a) Rectum entirely 
absent (Fig. 50) ; (b) Arrested in its descent at a point more 
or less removed from the anus, the latter being normal (Fig. 
51); (c) Opening into some other viscus, with anus either 
absent or present in its normal position (Fig. 52) ; (d) Normal 
rectum and anus, but either ureter, bladder, vagina, urethra, or 
uterus opening into them (Figs. 53, 54, 55, 56, 57, 58). 

Treatment. — This depends entirely upon the completeness 
of the atresia. When complete, relief must be sought at once 
by surgical means in order to provide an exit for the faeces. 
On the other hand, where atresia is only partial and a suffi- 
cient exit for the meconium and fluid fseces exists, it is better 
to postpone operative measures until the child is stronger and 
better able to stand an operation. In these cases, while waiting 

172 



MALFORMATIONS OF ANUS AND RECTUM 173 

for a more propitious time to operate, the opening already 
existing may be still further dilated and thus be made to give 
freer exit to fasces. 

The chief object to be sought in all operative procedures 
for the correction of these malformations should be the 
restoration of the parts to their normal functional activities as 
nearly as possible. 




Pig. 47. — Entire absence of anus. 



William M. Mastin, of Mobile, Alabama, has given the 
following resume of the surgical treatment of anorectal im- 
perforation in the new-born. 

I have taken the liberty of quoting- verbatim from his 
article : 

" By the ancients this deformity was scarcely considered 
as amenable to the surgeon's skill if we interpret aright the 



174 DISEASES OF ANUS, RECTUM, AND SIGMOID 

teachings of the Arabic and early Greek and Roman physi- 
cians. The first authentic mention of such surgical interven- 
tion of which we possess any knowledge is the classical case 
recorded by Paulus ^Egineta, in about the seventh century, 
who successfully operated upon an atresic anus in a neAV-born 
infant by perineal incision and dilatation. This operation, 




Fig. 48. — Anal opening at some abnormal point on the perinaeum, scrotum or sacrum. 



however, was little more than a blind plunge of the knife into 
the rectal pouch; but, nevertheless, the method grew in popu- 
larity, and as performed either with the bistoury or the trocar, 
or a combination of incision and puncture, followed by pro- 
longed mechanical dilatation, was the procedure in vogue for 
hundreds of years. Hence we find the noted German surgeon, 
Laurence Heister, in 1768, and Benjamin Bell, of England, in 
1787, advocating the method with but slight modifications, 



MALFORMATIONS OF ANUS AND RECTUM 175 

and yet again having the sanction of Copeland Hutchinson in 
1822. In France the operation received renewed impetus 
through the publication of a number of successful cases by 
Breschat in 1834, which was further accentuated by the report 
of Roux de Brignolles the next year. The latter operator 
improved the operation somewhat by advising that the fibres of 
the anal sphincter be carefully preserved during the perineal 




Fig. 49. — The rectum ends in a blind cul-de-sac posteriorly to the anus 
into the vagina. 



the anus opening 



dissection. Then came Berard, in 1844, Vidal de Cassis, 
Guillon, Malgaigne, and Velpeau in the same country, together 
with Dieffienbach, who also advised resorting to colotomy if 
the perineal incision failed to open the rectal cul-de-sac. About 
the same period (1800) Dr. John P. Campbell, of Flemings- 
burg, Kentucky, was the first surgeon in our own country to 
put the operation into successful practice. 



176 DISEASES OF ANUS, RECTUM, AND SIGMOID 

" The technic thus performed varied only in the depth, 
length, and direction of the perineal incision; and the first 
really important surgical advance was made by Amrissat in 
1835, when he recommended and employed a rational peri- 
neal operation or true proctoplasty. This surgeon formulated 
the rule that a careful dissection of the perinaeum, extensive 
if necessary, be made to expose the rectal ampulla, which 




Fig. 50. — Rectum entirely absent. 



should be freely detached from the surrounding tissues, and, 
after evacuation of its contents, drawn down to the perineal 
incision, and the mucosa accurately sutured to the skin 
margin without undue tension. The all-important feature of 
Amussat's operation was the union of the mucous membrane 
of the enteron with the skin, by this means preventing the 
contraction of the opening which, in the previous methods, 



MALFORMATIONS OF ANUS AND RECTUM 177 

always narrowed into a simple fecal fistula, necessitating 
constant dilatation to permit discharge of the contents of the 
bowel. In those cases where the terminal end of the rectum 
can be easily reached through the perinseum, this method, with 
but trivial changes, is the one generally employed to-day. 

" Amussat practised in his early operations a T-shaped 
cut, the central or upright limb of which extended from the 




Fig. si. 



-Rectum arrested in its descent at a point more or less removed from the anus, the 
latter being normal. 



centre of the anal area posteriorly to the coccyx, the transverse 
bar passing across the perinaeum from one tuberischium to 
the other. The anatomical objections resulted in his rejecting 
this incision and adopting the simple straight section extend- 
ing along the mid-line of the perinseum from the perineoscrotal 
juncture in the male, or the vulvular commissure in the female, 
to the coccyx. 
12 



178 DISEASES OF ANUS, RECTUM, AND SIGMOID 

"Some years later (1844) Stromeyer suggested that, in 
those instances where a perineal dissection failed to disclose 
the enteron, the peritonaeum be deliberately opened through 
the perineal wound, the cavity explored by the finger, and the 
existence and location of the rectum accurately determined. 
This was a step in advance of his time, but it was never put to 
practical use until 1872, when Lieserink for the first time 




-Rectum opening into some other viscus, with anus either absent or present in its 
normal position into urethra. 



utilized the suggestion with a happy result. Since then, the 
operation has been performed by a number of operators." 

In those forms of malformation in which there is com- 
plete occlusion, immediate and radical surgical interference is 
necessary and should be done under strictly antiseptic precau- 
tions, but without a general anaesthetic, as this is not well 
borne by children. 



MALFORMATIONS OF ANUS AND RECTUM 179 

Means for Locating the Rectum. — The presence of the 
rectum is sometimes indicated by a greenish tinge in the skin 
of the perineum, when the rectum lies directly beneath it ; its 
near approach to the surface may also cause a bulging; palpa- 
tion may also be used with good results, and even better results 
expected from percussion. 




Fig. 53. — In which the rectum opens at the glans penis. 



If these methods fail, then dissection may proceed on 
general principles without such aids in locating the rectum, 
but I would positively interdict, under any circumstances, a 
former recommendation of introducing a trocar or an explor- 
ing needle into the perinseum, either for diagnostic purposes 
or for immediate relief of the over-distended rectal pouch, a 
far too rash and inaccurate procedure in the light of present 
knowledge. 



180 DISEASES OF ANUS, RECTUM, AXD SIGMOID 

The Operatiox. — Let a straight incision be made begin- 
ning at the normal position of the anterior margin of the anus 
and extending backward to the tip of the coccyx ; this incision 
should also extend through the subcutaneous tissue. If there 
be a rudimentary anus the incision should begin at its posterior 
margin, when the external sphincter is exposed, or, in its 
absence, the fibrous band that replaces it should be pulled 




Fig. 54. — In which the rectum opens into the vagina. 



gently apart instead of being excised. Still failing to find the 
rectum, the dissection should be continued upward and back- 
ward in the hollow of the sacrum, in order to avoid wounding 
the pelvic organs. When found it should be loosened from its 
attachments, if any, and if possible brought out through the 
wound, before being opened. When, on account of the short- 
ness of the mesorectum, or of great distention of the rectal 



MALFORMATIONS OF ANUS AND RECTUM 181 

pouch, this cannot be done, a trocar may be introduced and the 
contents drawn off, which will generally allow the bowel to 
be drawn down to the margin of the skin wound. In either 
case, before opening the sac the wound should be well packed 
between its sides and the rectum with sterile gauze. After the 
bowel contents have been drawn off, enlarge the opening, draw 
down and stitch the mucous membrane to the skin margin of 




Fig. 55. — In which the rectum opens into the bladder. 



the wound, the serous and muscular coats being allowed to 
retract. This will protect the perineal wound from contact with 
the fecal discharges. If the rectal pouch cannot be drawn down 
sufficiently to attach its mucous membrane to the skin margin 
of the wound at the point where the anus should normally be, 
then it may be attached to the point nearest this, where it would 
reach without too much tension. 



182 DISEASES OF ANUS, RECTUM, AND SIGMOID 

In order to give a broader raw surface for attaching the 
mucous membrane of the bowel, and to protect the wound 
more effectually from discharges, the recommendation of 
Vincent should be carried out, namely, cut away two elliptical 
flaps of skin, one from each side of the perineal wound. After 
the mucous membrane has been sewed to the skin margin, the 
posterior part of the perineal wound may be closed w T ith deep 




Fig. 56. — In which the rectum descends posteriorly to the anal canal. 

silk or chromicized cat-gut sutures, care being taken to draw 
together the fibres of the external sphincter muscle. 

The mucous membrane of the rectum should be stitched to 
the skin margin of the wound with sterilized cat-gut, in a con- 
tinuous suture, for each side of the rectum only. If there is 
much tension pass also an anchor suture either through the 
external walls of the gut or the mesorectum, out through the 
skin on either side and tie over a wad of gauze. 



MALFORMATIONS OF ANUS AND RECTUM 1#3 

When the rectum is arrested high up in the pelvis, bear 
in mind the difficulties to be encountered from the very small 
measurements of the outlet in the pelvis of an infant. To 
more fully appreciate how narrow this space, I give the 
measurements of the normal infantile pelvis. Between the 
tuberosities of the ischium, from y 2 to 2 cm. ; from scrotum 




Fig. 57. — In which the peritoneal cul-de-sac extends between the rectum and anus. 



to coccyx, from 4 to 4^ cm. ; from posterior commissure of 
vagina to coccyx, from 3 to 4 cm. This only gives a maxi- 
mum length of 4 cm., and a maximum breadth of 2 cm. The 
depth of pelvis from the tip of coccyx to promontory of the 
sacrum is only about 6 cm., and measurements may be still 
further reduced in these abnormal cases. In order to increase 
the space in the direction where there is most room, namely, 
the hollow of the sacrum, it is better to follow the recom- 



184 DISEASES OF ANUS, RECTUM, AND SIGMOID 

mendation of Vincent to extend the incision up through the 
coccyx and lower portion of the sacrum, splitting them through 
the centre with scissors, as these bones have not become com- 
pletely ossified. This leaves intact the normal attachment of 
the anal and rectal muscles and affords ample room and a 
good view when the wound is held open by retractors. 




Fig. 58. — In which a fibrous cord connects the blind ends of the anus and rectum. 



If, after splitting up the coccyx and the lower portion of 
the sacrum, the rectal pouch should be found so short that it 
will have to be attached at this end of the wound, let the car- 
tilaginous sections of these bones be carefully dissected out 
before the rectal pouch is attached, otherwise the rectum will 
eventually be included in an osseous outlet. It would be better 
to introduce a sound in the male bladder, or in the vagina, 



MALFORMATIONS OF ANUS AND RECTUM 185 

before beginning to search for the rectal pouch, to avoid 
wounding these organs. A careful watch should always be 
kept for the fibrous band which sometimes leads from the 
imperforated anus to the rectal pouch; when found, follow it 
up closely as a certain guide to the rectal pouch. 

If not found in the hollow of the sacrum, continue the 
search forward and upward in the peritoneal cavity, where it 
may be found attached to the promontory of the sacrum, or to 
its sides, in which case it is likely to be entirely enveloped by 
the peritoneal fold by which it attaches itself to the bony 
framework of the pelvis. When this is the case, the rectal 
pouch must be enucleated before it can be brought down. A 
difficult procedure, and I deem it wiser when such a condition 
is recognized either to do an inguinal colotomy or to bring 
down a loop of the sigmoid and attach it to the perineal wound. 
In all cases where the peritoneal cavity has been opened, it 
must be closed, or packed with sterile gauze before the rectal 
pouch is opened. If impossible to bring the rectal pouch out- 
side the peritoneal cavity, close the cavity and pack off the 
perineal wound in order that it may be utilized at a later date, 
if the rectal pouch should descend, as it sometimes does, and 
let an inguinal colostomy be done at once. 

Treatment of the Anal Cul-de-sac. — In those cases in 
which the anal cul-de-sac is fully developed, but the rectum 
does not unite with it, but is more or less removed from it, as 
illustrated in Fig. 51 and described in subdivision b, under 
" Malformations of the Rectum," the end-to-end union between 
the anal cul-de-sac and the rectal pouch, which would naturally 
suggest itself as the best method for meeting such a condition, 
is very difficult to perform and uncertain in its results. 

Experience has shown it to be better to dissect away the 
lining membrane of the cul-de-sac entirely, including the skin 
around the anal margin, also to bring the rectal pouch down to 
the margin of the skin, open it and suture its mucous membrane 
there. This can be done without much dissection if the rectal 
pouch is in close proximity to the anal cul-de-sac. 



186 DISEASES OF ANUS, RECTUM, AND SIGMOID 

C ototomy in Cases of Imperforate Anns. — Some surgeons 
recommend colotomy as a preliminary proceeding to the peri- 
neal operation in all cases where the rectal pouch cannot be 
definitely located without deep dissection. This is claimed to 
be more certain and less serious than proctoplasty, and not to 
interfere with the subsequent establishment of the anus at its 
normal site when the child is older and better able to stand 
such a serious operation. The necessary abdominal wound for 
the colotomy, it is urged, can first be used for locating the 
rectal pouch, and if found within easy reach of the peringeum 
the abdominal wound can be closed and the perineal operation 
done immediately. 

Remember, when a colostomy is to be done, that in infants 
the sigmoid flexure is frequently found on the right side. 

Treatment of Abnormal Narrowing. — Where only a 
decided narrowing of the anal canal with a reasonable exit 
for fecal matter exists, dilatation with rectal bougies may be 
all that is necessary until the child is older and sufficiently 
strong to stand the necessary surgical operation. 

Treatment of Partial Occlusion by a Band. — There can be 
no good reason for not removing this at once, after which the 
anus should be well dilated. 

Treatment of Complete Occlusion by a Membranous Dia- 
phragm. — This consists of a simple crucial incision of the 
membrane with subsequent dilatation, but it is well to examine 
for a possible second membrane higher up. 

Treatment of Cases in which the Rectum Opens at Some 
Abnormal Position on the Surface of the Body. — As the open- 
ing is generally sufficient to afford relief during infancy and 
the discharges are mushy, operative procedure can be delayed 
until the child is better able to bear it. 

If the abnormal opening is not too far removed from the 
site of the normal anus, the abnormal channel may be dis- 
sected out back to the rectal pouch, carried clown to the site of 
the normal anus, and there attached. When too far removed 
to carry out this suggestion, let the rectal pouch be searched 



MALFORMATIONS OF ANUS AND RECTUM 187 

for by dissection at the site of the normal anus, as previously 
recommended. When found, it may be separated from the 
abnormal channel, through which it relieves itself, the prox- 
imal end of which should be closed, and the rectal pouch 
brought down and attached at the normal site of the anus. 
The abnormal channel will be likely to close gradually if the 
necessary precaution has been taken to cleanse it thoroughly 
before closing the proximal end. If it fails to close itself, it 
may subsequently be dissected out. 

The following cases are an exception to the deferring of 
such operations. Where the abnormal opening is at the 
prepuce, glans penis, or on the scrotum, immediate operation 
for the restoration of the normal opening should be done. 
Where the opening is at some remote part of the body, it 
would be useless to search for the rectal pouch beneath the 
perinaeum. In such cases it will generally suffice to search for, 
and bring down a loop of the sigmoid or colon, suture, and 
open it at the normal anal site. 

Treatment of Cases in which the Rectum Opens into Some 
Other Viscus. — When the rectum opens into the bladder, an 
immediate operation is demanded, or death will result in a 
short time from infection. The operation always requires an 
abdominal section. If after opening the abdominal cavity the 
communication of the bowel with the bladder is found to be 
high up where it can be reached easily, it is perfectly feasible 
to divide the channel of communication between them, invagi- 
nate the openings into each, and suture them; but there must 
first be provided some external means of escape for the fecal 
matter, and this may be done either by means of a proctoplasty 
or a colotomy. When the opening into the bladder is very 
low down, and it is difficult to suture with any degree of 
certainty, it will be better to make a permanent inguinal anus 
and close up the lower end of the colon entirely. 

Now when the rectum opens into the urethra you have a 
condition far more favorable for operating, nor is there the 
same need for immediate operation, the rectal pouch being 



188 DISEASES OF ANUS, RECTUM, AND SIGMOID 

always lower down, and nearer the pelvic floor. The proximal 
end of the abnormal channel in these cases may even be 
utilized, after being divided and enlarged, to bring down and 
stitch at the site of the normal anus ; the remaining portion of 
the abnormal channel will close voluntarily. 

Treatment when the Rectum Opens into the Vagina. — • 
While the abnormal passage may be free enough to allow the 
exit of meconium, yet an imperforate hymen may obstruct it; 
a condition readily recognized by the bulging of a greenish 
membrane between the vulva. This obstruction may be over- 
come immediately by a crucial incision of the hymen. If the 
abnormal passage between the rectum and vagina is not suffi- 
cient to allow free exit to the meconium it may be dilated by 
bougies, a uterine dilator, or even incised if necessary, but 
radical operation for the relief of this malformation should be 
postponed to a more favorable age, from three to five years. 
I have now a similar case under observation, a child about two 
years of age, waiting for a more favorable time. She relieves 
herself satisfactorily, and is well nourished. 

Louis J. Hirschman, of Detroit, Michigan, reported to the 
American Proctologic Society, June, 1909, two cases where 
the rectum opened into the vagina, in both of which they had 
been allowed to continue until adult life, when he operated on 
both cases successfully by the Rizzoli method. 

Alois B. Graham, of Indianapolis, Indiana, reports a sim- 
ilar case of a child eight weeks old, operated on by him 
October 4, 1909, where the rectum opened into the vagina just 
posterior to the hymen. The anus was normal, but did not 
end in a blind cul-de-sac, nor was it occluded by a membranous 
diaphragm as is usually the case in such abnormalities, but 
opened into a blind pouch behind a bulging rectum, three 
inches in length and one-half inch in width. The rectal pouch 
was found to be attached anteriorly and laterally. The blind 
rectal pouch was drawn outside the anal margin for more 
than one inch ; the anterior and lateral attachments separated ; 
a longitudinal incision sufficient to admit the index finger 



MALFORMATIONS OF ANUS AND RECTUM 189 

made in the rectal pouch and the rectum emptied of its faeces. 
The redundant rectal pouch that protruded beyond the anal 
margin was cut off for about three-fourths of an inch and the 
edges sutured ; the proximal end being attached to the skin at 




Fig. 59. — A case where the rectum opened into the vagina and the anus into a blind pouch 
posteriorly. (Before the operation.) 




Fig. 60. — A case where the rectum opened into the vagina and the anus into a blind 
pouch posteriorly. (After the operation.) 



the anal margin. Primary union ensued and the patient made 
a rapid recovery. The accompanying illustrations show the 
condition of the child before and after the operation (Figs. 59 
and 60). 



190 DISEASES OF ANUS, RECTUM, AND SIGMOID 

I give the method generally used for the relief of this mal- 
formation, one recommended by Rizzoli (Gross's " System 
of Surgery," Vol. ii, page 205, sixth edition) : An incision 
being made from the posterior margin of the vagina backward 
to the point where the normal anus should be, the perineal 
tissues are carefully loosened from their attachments all around 
and the vaginal anus dissected out intact and dragged down 
to the position of the normal anus, where it is carefully 
attached. The perineal tissues in front of the bowel are then 
brought together by buried cat-gut or deep silver-wire sutures, 
the mucous membrane of the vagina is also carefully brought 
together and sutured, thus restoring completely the rectal- 
vaginal septum, and closing all communication between the 
two organs. 

By this procedure the natural opening in the rectum is 
preserved with all of its sphincteric power, and, if clone under 
antiseptic measures, the risk of primary union or retraction of 
the parts is practically nil. 

If two openings in the vagina exist far apart, as some- 
times happens, it is better to use the one nearer the normal anal 
opening, as above described. Then dissect out and close the 
one farther away. 

Treatment when the Rectum Communicates with the 
Uterus. — These are so rare that no definite rule for operating 
has been laid down. It would seem proper, however, in such 
cases, first if possible to establish an anus at the normal site, 
and to follow this by a laparotomy, division of the canal 
connecting the two organs, an inversion and suturing of the 
aperture in each. 

Treatment when the Rectum and Anns are Normal, bat 
Have Opening into Them the Ureters, Uterus, or Vagina. — 
In those cases in which the ureters terminate in the rectum, 
the bladder was found absent, when of course an operation 
could not be done. When the uterus or vagina opens into 
the rectum, the same course may be pursued as in the con- 
verse conditions already described. 



MALFORMATIONS OF ANUS AND RECTUM 191 

After all the recommendations given for operating on these 
malformations, it would seem the ultimate results, as shown 
by Hardonin (Archives General es de Chirurgic, Paris, Nov. 
25, ii, No. 11, pages 445-551), are far from being satisfactory, 
if judged by his summary of two hundred and twenty-three 
cases of anorectal imperforation, in which six different tech- 
nics were applied in as many groups of cases. Fully 55.2 
per cent, of the patients succumbed during the first week after 
the operation; 44.4 per cent, during the first month; 22.8 per 
cent, were lost sight of during the first year, while the inter- 
vention proved successful in 13.55 P er cent. — the results 
known for one year and over — and in 5.8 per cent, for twenty 
years. The results with the Littre method were much more 
satisfactory than with the others, but even at best the func- 
tional results of operative treatment are disappointing. Out 
of a total of two hundred and twenty-three patients only 
sixteen lived to puberty and thirteen to adult life. Stricture 
is the most formidable complication, but incontinence is fre- 
quent and prolapse occasionally observed. In one case the 
kidney protruded from the wound. The Littre method is 
merely to make an artificial anus in the left iliac region. 



CHAPTER IX 



ANORECTAL FISTULA 



An anorectal fistula is an abnormal channel of communica- 
tion between the rectum or anus and the surrounding tissues 
or the surface of the neighboring skin. It originates in an 
abscess cavity, which, after having its pus evacuated, col- 
lapses to form a tortuous canal. If these fistulas communicate 
with the rectum or anus, they refuse to heal without surgical 
intervention, most probably on account of continued reinfec- 
tion of the canal. They are classified, according to the 
location and number of their openings, as complete and 
incomplete. 




Fig. 6i. — Showing complete and incomplete fistula. A, shows blind external fistula; 
shows complete fistula. 



Complete Fistula. — This has both an external opening on 
the skin surface and an internal opening into the rectum or 
anus (Fig. 61, B). 

Incomplete Fistula. — Here there is but one opening, either 
into the rectum or anus or on the skin surface. When opening 
into the rectum it is known as a blind internal fistula, and 
when on the skin surface only as a blind external fistula (Fig. 
61, A). These classifications are sometimes subdivided by the 
character of the tissues in which the fistula appears, as sub- 
192 



ANORECTAL FISTULA 193 

cutaneous, submucous, submuscular, and subaponeurotic. 
They may be simple, when due to infection by ordinary pus 
organisms ; specific, when due to specific organisms, as syphilis 
or tuberculosis; complex, when there are numerous fistulous 
tracts with several external openings ; complicated, those in 
which the pelvic bones or the adjoining pelvic organs are 
involved. The specific types are those due to tuberculosis, 
carcinoma, and syphilis. 

The relative frequency of fistula as compared with other 
rectal diseases ranges from one-third to two-thirds of the 
whole number operated upon ; the former is probably more 
correct. 

While the large majority originate in an abscess cavity, 
occasionally they are due to penetrating wounds which extend 
from the external surface into the rectal cavity, such as gun- 
shot or bayonet wounds, etc. Ulceration and burrowing from 
diverticula of the upper portion of the rectum and lower sig- 
moid may also give rise to fistulous openings on the skin sur- 
face of the perinaeum or in the rectum. 

The generally recognized fact that fistula in ano rarely if 
ever heals spontaneously, gives rise to the question, Why are 
they the exception? This can readily be understood in the 
case of a complete fistula, and also of the internal incomplete, 
which opens directly into the rectum, from which the fistulous 
tract is constantly being reinfected ; but not so with the external 
fistula, unless its connection with the bowel exists much more 
frequently than is generally supposed. Its sinus is often so 
tortuous, its opening so valve-like, that connection with the 
rectum cannot be demonstrated. I strongly incline to the 
belief that such an explanation gives a satisfactory solution 
of the question in a large majority of cases. Many other 
explanations, such as mobility of the rectal wall due to the 
respiratory movements, together with involuntary peristaltic 
action, have been assigned as the cause of these fistulous 
tracts not healing spontaneously, but I think the one given 

13 



194 DISEASES OF ANUS, RECTUM, AND SIGMOID 

above, namely, its constant reinfection by its tortuous con- 
nection with the rectum and imperfect drainage, the only 
satisfactory one. 

Sex. — According to statistics, anorectal fistulae are much 
more frequent in men than in women, most likely due to 
the fact that the former are more exposed to accidents likely 
to produce perirectal abscesses, and pay less attention to per- 
sonal cleanliness. While fistulas are not limited to any dis- 
tinct age, they occur more frequently in middle life. 

Constitutional Causes and Complications. — Any condition 
that lowers the general vitality predisposes to the formation of 
abscesses and fistulae. 

Tuberculosis. — As an etiological factor in the production 
of fistulae, tuberculosis may act both indirectly through a 
lowering of the general vitality, and directly, which is far 
more frequent, by primary inoculation of an abrasion or an 
injury with the tubercle bacilli, or by a secondary infection, 
through the lymph- or blood-channels. The finding of tubercle 
bacilli in the scrapings from fistulous tracts has certainly 
demonstrated the fact that tuberculous fistulse are far more 
frequent than generally supposed, and that such a condition 
exists in many cases where there is at the time of the operation 
no evidence of its existing elsewhere in the body, at least in an 
active state. This has been especially so in my experience, 
since I have made it a routine practise to have the scrapings 
from all anorectal fistulae examined. 

Syphilis. — So far as is known, the influence of syphilis 
in the production of fistula is almost entirely secondary to 
stricture of the rectum, and in such cases the fistula is usually 
a complicated or complex one, due to perforation of the rectal 
wall by ulcerative processes and infection of the perirectal 
tissues. Even though the fistula is a result of simple infection 
by pus organisms, yet the Spirochceta pallida may confidently 
be expected to be present. 

Notwithstanding the probable correctness of the statement 
just made, that the destructive processes in these cases which 



ANORECTAL FISTULA 195 

result in the production of fistula are due to the ordinary pus 
organisms, it is a well-recognized fact that in many it is 
almost impossible to get such fistulse to heal, even after being 
opened up, until the patients are placed upon an antisyphilitic 
treatment. 

Complications. — Two cases of persistent albuminuria have 
been reported to me by Dr. C. W. McElfresh, in which the 
albuminuria disappeared entirely after the fistula had been 
operated upon and had healed, though the albuminuria had 
persisted for two years before operation. 

Symptoms. — The primary symptoms of those attending 
the formation of the abscess cavity have passed when, as a 
fistula, it is brought to our attention, so I only take up such 
symptoms as exist in the different forms of fistula. 

Blind External Fistula. — Here the symptoms are a thin 
seropurulent discharge, with immediate surrounding tissues 
thickened and brawny; the aperture may close for a limited 
time, during which the discharge ceases, and is followed by 
a feeling of fulness and discomfort from the accumulation of 
pus in the tract, but these latter symptoms disappear upon the 
reopening of the aperture. This opening and closing of the 
aperture may go on indefinitely, but it may remain closed 
long enough to cause the pus to burrow and to open at another 
point on the surface, or even into the rectum, thus forming 
what may appear to be a blind internal fistula but in reality 
one resulting in the formation of a complete fistula, as the 
external aperture, which has been closed temporarily, will 
soon reopen. 

Upon palpation of the parts lying along the route of the 
sinus the tissues will be found thickened and indurated; deep 
pressure will give rise to some pain and will generally result 
in the emission of a drop of pus at the external opening, even 
though it may have been temporarily closed. There is little 
if any pain on defecation; the patient often remains in the 
best of health, and even increases in weight. 



196 DISEASES OF AXUS, RECTUM, AND SIGMOID 

Blind Internal Fistula. — The symptoms of this variety are 
more obscure, whereas the pain, especially on defecation, is 
more pronounced and there is more or less spasm of the 
sphincter present, and if it has existed for any length of time 
there is likely to be hypertrophy. These symptoms subside and 
recur with a decrease or increase of the discharge. There is 
little to be gained from palpation on account of the fistula 
being so generally deeply seated, unless one finger is intro- 
duced into the rectum, when the induration may be felt. If 
the opening is directly at the margin of the anus, by separating 
the buttocks well and requesting the patient to bear down, 
pus can generally be seen exuding from the opening; if not, 
a single-bladed speculum may be introduced on the opposite 
side from where the induration has been felt, when by drawing 
back the opposite wall of the anus the pus can usually then 
be seen. A probe introduced into the opening with the end 
bent to the necessary angle to introduce it to the bottom of 
the sinus will show the depth and direction of the tract. 

Complete Fistula. — This variety is far more readily diag- 
nosed than the preceding one. In addition to the symptoms 
previously enumerated in the other varieties, there is an 
increase in the discharge, escape of gas and faeces through the 
opening; also the probe can be readily passed through the 
canal into the rectum. An examination by palpation with one 
finger in the rectum will sometimes elicit the indurated tract 
leading up to the internal opening. 

The external opening will generally appear as a pouting 
tubercle, or a small cicatricial depression ; it may appear 
between the radial folds of the anus, or sometimes, in cases of 
tubercular fistula, in the midst of a ragged ulceration. 

The internal opening may be either in the form of a 
small papilla, in the midst of an ulceration, or at the base of 
one of the crypts. When the internal opening is not so readily 
located, colored fluids, such as methylene blue, or milk, may 
be injected forcibly through the external opening into the 



ANORECTAL FISTULA 197 

tract. After waiting some minutes and wiping the fluid care- 
fully away from the external parts, the rectum may then be 
inspected through a proctoscope for the fluid. This method 
is likely to fail if the internal opening is valve-like, and there- 
fore is no positive proof that the fistula is not complete. There 
is such a condition as a complete intrarectal, or intra-anal 
fistula, which consists in two openings on the mucous surface, 
connected by a fistulous tract. While this is rare in the rectum, 
it is not so in the anus. 

There may be many external openings, but all connected 
with one abscess cavity by more or less tortuous tracts, and 
the abscess in turn is connected with the rectum; the latter, 
which is the important one, should be opened up during the 
operation. This can best be done by first opening up the 
general abscess cavity, when the probe can be easily passed 
from that through the internal opening. 

The submuscular or subaponeurotic fistulas are attended 
with much graver constitutional disturbances ; the pus burrows 
much more extensively, and induration of the tract and infil- 
tration of the surrounding tissues are much more pronounced 
than in the subtegumentary variety. 

Origin. — It is very important to determine the origin of 
a fistula. The mere fact of one or more fistulous openings 
being found near the anal margin, on the perinseum, or but- 
tocks, does not necessarily imply an anorectal fistula. The 
fistulous tract may even encircle the rectum without entering 
it, or the anus, and finally be traced to the urethra, glands of 
Bartholin, the ovary, broad ligament, to a necrosed pelvic 
bone, even to a psoas abscess, or to a dermoid cyst, which 
may break down and rupture into the retrorectal space. 

Fistulse resulting from carcinomas and strictures of the 
rectum' and secondary to these conditions cannot be relieved 
until they are successfully treated. 

Pathology of Fistula. — It is very important, whenever 
possible, to determine the pathological character of a fistula ; 
not always easily done until the fistulous tract has been opened 



198 DISEASES OF ANUS, RECTUM, AND SIGMOID 

up and the scrapings examined microscopically, unless the 
external opening is either very large or surrounded by an 
ulcerated surface. There may be some special local charac- 
teristics or general conditions that may lead to a suspicion of 
the true character of the fistula, especially where there is car- 
cinoma, stricture of the rectum, or pulmonary tuberculosis. 
Let the latter condition influence our method of operating, even 
in the absence of positive information from the scrapings of 
the fistulous tract. In tubercular fistula there is but one abso- 
lutely certain method of ascertaining its true character, a 
microscopic examination of the scrapings from the fistulous 
tract, and the same can be said of carcinoma and syphilis. . 

The diagnosis of a urinary fistula, opening around the 
anus, may be made from the presence of the urine in the dis- 
charge, and by the administration of a capsule of methylene 
blue by the mouth, which will color the urine blue, and if 
any should come through the fistulous tract it will color it 
likewise. 

Prognosis. — The condition of the patient, the amount of 
tissues involved and the pathological character of the fistula 
determine this. The present opinion that fistula is easily 
cured is by no means borne out by statistics. Tuttle has 
shown that less than 45 per cent, of 2196 cases collected by 
him are even claimed as cures, and further says : " A very 
large majority of the cases of fistula operated upon in hospitals 
and treated by general surgeons are failures, so far as cure is 
concerned." 

All sinuses diverging from the main channel should be 
most carefully sought for and opened up ; the internal opening 
sought with equal care; the utmost attention paid to subse- 
quent treatment of the fistulous tract; and even after this has 
entirely healed let the patient be examined occasionally to 
ascertain if there has been any subsequent breaking down of it. 

Very rarely cases of fistula have been known to heal spon- 
taneously, following the introduction of a probe. I had one 
such experience in a chronic case, although it was not a com- 



ANORECTAL FISTULA 199 

plete fistula ; but such results are entirely too rare to be hoped 
for, and would not justify delay in proper treatment. 

The unfavorable prognosis given above can be qualified, 
if the proper care is taken at the time of the operation and with 
the subsequent treatment. 

Prognosis in Tubercular Fistula. — It is a popular opinion, 
even among many of the profession, that tubercular fistulse 
should not be operated upon; an opinion well founded, if 
applied to cases that occur in advanced pulmonary tuberculo- 
sis, for many of these will succumb to the pulmonary disease 
before the healing of the local lesion, or will likely be very 
much aggravated by the shock of an operation, loss of blood, 
or the effect of a general anaesthesia. The most that can be 
done in such cases is to see that they are properly drained. 

These objections do not, however, apply to the strictly 
local tubercular fistula, as now frequently found. Under 
proper methods of operating (given later on) and the neces- 
sary care and attention in subsequent treatment, the results 
are most satisfactory. To secure these ends, radical methods 
should be used to remove the focus of infection, and to preserve 
the barriers set by nature to prevent a general infection. In 
addition, take special care to avoid such an infection through 
any other channel. 

Just a word regarding what is meant by " barriers set 
by nature." Examine carefully the tissues surrounding these 
fistulous tracts and it will be observed that just outside the 
layer of granulation tissue there is a fibrous, cicatricial wall 
throughout their entire extent, and a microscopical examination 
of a cross section of this infiltrated wall will show you that 
the number of tubercle bacilli and giant cells gradually de- 
creases the further you go beneath the granulation tissue until 
they disappear entirely on the denser portion of this infiltrated 
wall being reached. This is unquestionably a barrier set by 
nature to protect the tissues beyond this infiltrated mass, and 
it should be preserved most scrupulously by the surgeon, what- 
ever method may be used for the closure of the fistulous tract. 



200 DISEASES OF ANUS, RECTUM, AND SIGMOID 

As an illustration of this condition, I give an instance 
from my own case book : 

G. P., policeman, age forty-five; weight 180 pounds; very 
robust, with ruddy color, no cough, nor history of any pul- 
monary trouble, was operated upon by the author, at The 
Maryland General Hospital, December 29, 1906, for rectal 
fistula. The left buttock was very much swollen and inflamed; 
there were several fistulous openings on its surface, which 
could not be followed far beneath, and there was one just to 
the right of the anterior commissure into the anal canal. Upon 
laying open the skin on the buttock, between two of the open- 
ings, there was a mass of white fibrous tissue exposed which 
resembled a capsule, but on incision proved to be a dense mass 
of fibrous tissue adherent to the subcutaneous tissue. Sup- 
posing it to be a tumor which had broken down in places, 
I made an incision on either side, near each lateral border, for 
the purpose of dissecting it out, which was done (Fig. 62). 
The mass measured 6x3x2 inches, and was found to run 
deep down between the muscles of the buttocks, which in 
some instances were involved. The tract from the inner 
margin of the mass to the opening in the anal canal was then 
laid open and packed. The cavity left was so large that sutures 
were introduced to draw the edges partially together and to 
hold in the packing; and supplemented by adhesive strips 
(Fig. 63). There were found several large larvae, supposedly 
of flies, deep down in the sinuses of the growth. After the 
mass was taken out it was found to be composed principally of 
fat, riddled with sinuses which were surrounded by dense 
fibrous tissue from one-fourth to one-half inch thick. The 
tapering tail-like process that extended over the trochanter 
major was composed principally of muscle. Microscopical 
examination showed the growth to be tubercular in character. 
The patient made a slow but complete recovery, the large 
cavity filling in completely, and he is now perfectly well and 
robust. 



ANORECTAL FISTULA 



201 



James P. Tuttle has seen five cases in which general tuber- 
culosis rapidly followed operations for fistula, done in the 
manner advised by Salmon, following especially the recom- 
mendation to make the incision through the scarred tissues, 
in order to hasten absorption. 

Arthur Hebb, of Baltimore, Maryland, also reports one 
case of acute miliary tuberculosis following a carefully per- 
formed excision of the fistulous tract, yet in all these cases 




Fig. 62. — A case of tubercular fistula attended with extensive fibrous infiltration that 
resembled a tumor formation, and it was removed under this impression. 



there was neither history nor evidence of a pulmonary or 
general tuberculosis after a careful physical examination. 

It is also a well-known fact, that a number of patients with 
pulmonary tuberculosis have been seen who were very positive 
that they never had any cough, or pulmonary affection until 
after operative interference with their fistulse. In the light 
of suggestions so obtained, it is certainly our duty to pre- 
serve intact the barrier established by nature between such 
an infected area and the healthy tissues beneath. Therefore 



202 DISEASES OF ANUS, RECTUM, AND SIGMOID 

in operating, even on a suspected case of tubercular fistula, the 
incision should be made with a thermo, or a galvanoeautery 
knife, and care taken to cauterize only the granulation tissue 
of the tract, so that it shall not extend through the infiltrated 
fibrous layer. 

Treatment. — This may be either non-operative or opera- 
tive, according to the nature and severity of the case. 




Fig. 63. — The same case showing the edges of the wound partially approximated by 
sutures. 

Non-operative Treatment. — This does not imply that no 
cutting at all should be done, but only sufficient to allow the 
fistulous tract to be drained thoroughly. Make the existing 
opening larger by nicking its orifice in several places; and if 
possible, without giving too much pain, let it be sufficiently 
enlarged to introduce a small, sharp curette with which the 
canal may be scraped, or possibly cauterized. It is claimed 
that these measures, together with dilatation of the sphincter, 
which can be accomplished under local anaesthesia or one of 
the transient general anaesthetics (nitrous-oxide gas or ethyl 



ANORECTAL FISTULA 203 

chloride), will suffice to cure many cases of blind external 
fistula, and for such this conservative method is especially 
favorable. Failure to heal may reasonably indicate a com- 
plete instead of an incomplete fistula. 

Under this heading, also, I mention the injection of a 
saturated solution of nitrate of silver into the fistulous tract 
of a blind external fistula, which will frequently effect a cure 
if the variety has not been mistaken and it is not a complete 
fistula. Bennett, Goodsaull and Miles, however, advocate 
this method even in cases of complete fistula in which the 
internal opening is above the internal sphincter. Let this 
injection be followed immediately by an enlargement of the 
external opening of the fistulous tract for the purpose of 
allowing freer drainage. Injections of pure carbolic acid, or 
equal parts of iodine and carbolic acid have also been recom- 
mended, and still another means may be used to obtain the 
same results by introducing a loop of wire into the fistulous 
tract and heating it to a dull red heat by an electric current. 
An increase of the discharge for several days will follow any 
of these methods after which healthy granulations will spring 
up, and if the fistulous tract does not close within ten days 
from the time of treatment it may be repeated several times 
at such intervals. 

While the above methods are generally advised to be tried, 
first, because many cures can be claimed, and secondly, the 
risk is avoided that sometimes follows free incision of the 
sphincters, — incontinence, — I personally have not found them 
either satisfactory or successful. 

Operative Treatment. — Let as thorough a knowledge of 
the pathological conditions as possible be obtained, in order 
to guide the operator in the best method to be used under 
existing conditions. 

The use of the elastic ligature for cutting through the 
fistulous tract by continuous pressure, much in vogue some 
fifty years ago, need only be alluded to here, because it has 
become obsolete and has been superseded almost entirely by 



204 DISEASES OF ANUS, RECTUM, AND SIGMOID 

the knife, or cautery. The principal objections to that method 
are that it takes clays to accomplish what can be done with a 
knife, or cautery, in a few moments, and fails to reach any 
lateral sinuses which exist in connection with the main tract. 
When they do exist, they have to be laid open with a knife or 
scissors after the direct fistulous tract has been cut through by 
the ligature. 

I take, then, only three methods for special consideration 
under this heading; incision, excision, and excision with 
suture. 

Preparation of the Patient. — This will vary somewhat 
with the chronicity of the case. If the case presents itself 
soon after the rupture of the abscess cavity, and before the 
subacute symptoms have subsided, the toilet need only be 
that used in the preparation of rectal cases generally, namely, 
thorough scrubbing with green soap; thorough rectal irriga- 
tion; shaving the external parts, washing with a solution of 
bichloride ; dilating the sphincter and introducing gauze pack- 
ing. On the other hand, in chronic cases, especially where 
there is much purulent discharge, it is well to syringe out the 
fistulous tract every three or four hours, for one or two clays, 
with a solution of carbolic acid 1-40, or of bichloride of 
mercury 1-500. The bowels having previously been cleared 
out by a brisk purgative, given at least twenty-four hours 
before the time of the operation, let a large enema of tepid 
water be given about two hours prior to operation. 

Alfred J. Zobel, of San Francisco, California, has sug- 
gested injecting the fistulous tract with a saturated solution 
of permanganate of potash, just prior to operation, in order to 
trace the sinuses in their various ramifications. A solution 
of methylene blue has been suggested for the same purpose. 

The anaesthetic will depend upon the extent of the opera- 
tion, if that can be properly estimated before proceeding. In 
superficial cases an hypodermic injection of J^— 1 per cent, 
solution of cocain may be used. As it is almost impossible 
before opening up the main fistulous tract to know the extent 



ANORECTAL FISTULA 



205 



or direction of the sinuses that diverge from it, therefore the 
extent of the operation cannot be foretold in most cases, and 
local anaesthesia is restricted to a limited number; the large 
majority of them had better be done under a general anaes- 
thetic, either one that is transient, or more prolonged in its 
effects, according to the gravity of the case. Spinal cocainiza- 
tion can also be used in these cases with very excellent results, 
by those who are partial to this method. 




Fig. 64. — Showing position after the shoulder and knee strap is ap 



The extreme lithotomy position, with the hips well ele- 
vated, is the one I find most convenient ; the legs to be held in 
position by the strap that is attached just above each knee, 
passing over one shoulder, and beneath the other (Fig. 64). 

The instruments necessary are a grooved director, probe, 
sharp-pointed bistoury, a thermocautery for tubercular cases, 
scissors, artery forceps, curette, needles and needle-holder, if 
it is proposed to excise and suture the fistulous tract. 



206 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Pass a grooved director into the external opening through 
the tract, until it impinges against the mucous membrane of 
the bowel, readily felt by the index finger, previously inserted 
into the rectum. The internal opening is now searched for 
diligently, and when found, the director is passed through it. 
The finger is now hooked over the end of the director pro- 
truding into the rectum, and this director pulled out through 
the anal orifice. A sharp-pointed bistoury is then run down 
the groove of the director, from without inward, and all the 
tissues held on the director divided at right angles to the plane 
of the external sphincter muscle. If the course of the fistulous 
tract runs obliquely to the plane of the sphincter muscle, the 
tissues covering the external portion of the tract should first 
be divided down to the margin of the external sphincter, when 
the course of the director should be changed to a right angle 
with the sphincter muscle, which should then be divided. If 
impossible to find the internal opening of the fistulous tract, 
and yet the point of the director approaching so near the 
mucous surface that it can be plainly felt by the index finger 
in the rectum, I think it best to carry the point of the director 
as high up in the fistulous cavity as it will gO' without using 
force, and then push it through into the rectum. By such 
means you will know you have gotten above the internal 
opening if one exists in spite of your efforts to find it. Should 
the director not approach near the mucous membrane, nor 
pass around the bowel for any distance, you may safely con- 
clude the case to be one of blind external fistula, and all that 
is necessary will be to enlarge the external opening, curette 
the cavity, or fistulous tract, stretch the sphincter, and see that 
the proper drainage is maintained. The opening should close 
up in the course of ten days or two weeks. 

In case it is a blind internal fistula let the director be intro- 
duced through the internal opening to the bottom of the pre- 
vious abscess cavity, and the intervening tissues be divided 
down to the bottom of the cavity. I have devised a hawk-bill 
knife for operating on such cases, which will be found very 



ANORECTAL FISTULA 207 

convenient (Fig. 65). In either of these cases, after the 
fistulous tract has heen laid open, the granulation tissue should 
be gently scraped away with a curette, care being taken that 
the curette does not pass through the fibrous layer at the 
bottom of the tract. 

If you suspect the fistula to be tubercular, it should be 
laid open with a thermocautery knife, at a dull red heat, gently 
cauterizing the base of the tract also. If the fistulous tract 
has run up alongside of the rectum some distance before enter- 
ing it, after the division of the mucous membrane, from the 
internal opening down, it may be closed by sutures, care being- 
taken that the site of the internal opening and the remainder 
of the incision in the mucous membrane are so carefully closed 
to obviate danger from a subsequent leak. This internal open- 



Fig. 65. — Earle's hawk-bill knife. 

ing may be very high up in the rectum, when there is danger 
of dividing a large vessel by the usual incision. In such a 
case the mucous membrane may be divided up to the internal 
opening by pressure forceps, which are allowed to remain on 
until they cut their way through. If there should be more than 
one internal opening, the tracts leading to each should be laid 
open through their respective internal opening. Diverging 
sinuses -from the main tract under the mucous membrane 
should be carefully searched for and also opened up. By 
chance the fistulous tract has burrowed beneath the mucous 
membrane above the internal opening, making it unnecessary 
to extend the incision to the bottom of this fistulous tract, as 
the drainage secured by thoroughly opening the tract below 
from the internal opening out will be sufficient to secure its 
closure. The portion of the fistulous tract outside of the 
mucous membrane will then readily close, if properly drained 



208 DISEASES OF ANUS, RECTUM, AND SIGMOID 

and occasionally stimulated by local applications. The sutur- 
ing of the internal opening, together with the mucous mem- 
brane, will very much facilitate the healing of the fistulous 
tract. Where there is much cicatricial tissue surrounding the 
fistula, it should be dissected out as thoroughly as possible, 
provided the operator has eliminated tuberculosis. 

Let the wound be now well irrigated with sterile water and 
packed firmly with gauze, which should remain from twenty- 
four to forty-eight hours. The patient as a rule may be 
allowed to get up the second or third day, as the wound drains 
better if he is in an erect posture, even though only able to 
remain up a few minutes at a time : his general condition will 
be much improved thereby. 

After the first packing has been removed, the wound should 
be irrigated with sterile water, or a weak antiseptic solution, 
twice a day. and for some days several thicknesses of gauze 
may be laid between the freshly-cut surfaces of the wound to 
prevent them adhering together. 

Excision of Fistula. — This is a very effectual and satis- 
factory means of treating direct or complete fistula, where the 
amount of scarred tissue is not too extensive, and the cut ends 
of the sphincter would not be kept too far apart after the 
wound has healed. This is a very old method, having been 
practised long before that of simple incision, and is best 
adapted to old chronic cases, special care being taken not to 
destroy much of the external sphincter. 

Excision with Immediate Suture. — With the inception 
of antiseptic surgery it was natural to infer that this method 
would be eminently successful and the one always chosen in 
direct fistulae when not extending very deep or opening too 
high up in the rectum. Results have not nearly measured up 
to the expectations of the surgeons, having been followed by 
frequent recurrences, which were most likely due to sinuses 
extending beyond the excised area. As a result, the opera- 
tion is not half as frequent as it was a few years ago. Not- 
withstanding, it should not be discarded entirely, but used 



ANORECTAL FISTULA 209 

in short superficial and direct fistula, also in those superficial 
tracts that extend out on the buttocks, if the same are simple 
in character. All should be done under the most rigid anti- 
septic technic, especially with regard to previous treatment of 
the fistulous tract for several days, by injections of antiseptic 
solutions. The sphincter should be stretched, as previously 
recommended. 




■% 




\ 



X 



Fig. 66. — First step in excision of fistula. (Tuttle.) 

James P. Tuttle has probably the best and most ready 
means of doing the operation. He passes a long flexible silver 
probe through the fistulous tract from the external to the 
internal opening (Fig. 66), and allows the ends of the probe 
to extend beyond each opening sufficiently long so that, when 
bent upon itself, it will form a sort of traction loop by which 
the fistulous tract can be elevated above the surrounding 
tissues. An incision is made from one opening to the other 

14 



210 DISEASES OF ANUS, RECTUM, AND SIGMOID 

directly over the probe. After passing through the skin, the 
dissection is then deflected to each side, until it extends beyond 
and beneath the infiltrated fibrous layer, and continued until 
the dissection on each side meets beneath the floor of the 
fistulous tract. Special care should be taken to dissect out 
and leave intact the fibres of the external sphincter which pro- 
ject over, and external to, the fistulous tract (Fig. 67). 




Fig. 67. — Removal of a fistula threaded upon a probe. (Tuttle.) 

It will be seen that the fistulous tract with its surrounding 
infiltrated fibrous mass is thus removed intact when properly 
done and does not infect the fresh wound. If for any reason 
the latter becomes infected from the fistulous tract, either from 
inadvertently opening into it, or from having cut through a 
diverging sinus, the subsequent part of the operation, namely, 
the immediate suture, had better be abandoned and the wound 
treated as in simple excision. 



ANORECTAL FISTULA 



211 



The tract being removed satisfactorily, application of the 
sutures for the closure of the wound is the next step. To 
avoid too much tension on the internal sutures, pass several 
silkworm-gut sutures from one side of the wound to the other 
and beneath it; these to be only drawn taut and tied after the 
wound has been closed. The deeper portions of the wound 
are now brought together bv small-size silk sutures, cat-^ut 



r 




Fig. 68. — Method of introducing the sutures after excision of fistula. (Tuttle.) 



in any form being too uncertain to warrant its use in what 
should be a perfectly clean wound. If the incision is deep, 
two rows of continuous silk sutures should be used in closing 
the wound (Figs. 68 and 69). Pay special attention to bring- 
ing the cut ends of the external sphincter in apposition and 
holding them together by interrupted sutures ; there should also 
be a reinforcing suture either of silkworm-gut or silver wire. 



212 DISEASES OF ANUS, RECTUM, AND SIGMOID 

for holding in position the ends of the sphincter, and to relieve 
the strain upon the interrupted silk sutures; place this just at 
the margin of the skin and mucous membrane. The entire 
length of the incision should now be sealed with iodoform 
collodium. A slip of iodoform gauze should now be laid over 
the wound, and especial care taken to introduce it within the 




v 



_ 



Fig. 69. — Final step in closing fistula. (Tuttle.) 

anus, letting it cover and protect the inner angle of the wound. 
Let a single-bladed speculum now be introduced into the 
rectum over these dressings so as to hold them in position 
while the packing is being removed from the rectum. Now 
introduce a medium-sized drainage-tube, wrapped with gauze 
and rubber protective, and leave it in the rectum, when the 
external dressings may be applied. A hypodermic of morphia, 



ANORECTAL FISTULA 213 

34 grain, can now safely be given to control the pain, and to 
confine the bowels for live or six days ; this may be repeated 
every two or three hours until the pain is relieved. 

The diet should consist of egg albumen, broths, eggs, a 
small amount of meat, and a very limited allowance of bread; 
after the third day, fruit juices followed by stewed fruits may 
be given. The patient should be confined to bed until after 
the bowels are moved. On the fifth day j/2 ounce of olive 
oil should be administered midway between the meals, and at 
bed-time ; this to be followed by 2 drams of compound 
liquorice-powder early on the morning of the sixth day, and 
repeated in six hours if not effectual. 

When this method succeeds there is a very decided gain in 
time of healing and functional results over the open incision, 
and the patient should be given the advantages of such a 
method in properly selected cases. A failure can be recognized 
directly after the first movement of the bowels and the wound 
then laid open under the influence of local anaesthesia, when 
the patient will be in exactly the same position as though the 
method of excision, without suture, had been used in the 
first instance. 

Complex Fistula. — Any perirectal abscess may result in a 
complex fistula. If the inflammatory stage has involved a 
large amount of tissues around the anus and rectum, or an 
ordinary-size abscess has been badly drained, it will lead to 
extensive burrowing and result in such. 

These are sometimes characterized as watering-pot fistulae 
(Fig. 70), on account of the numerous external openings to 
the tortuous tract, and, again, as " horseshoe " fistulae when 
they assume this shape, extending almost around the anal 
margin. Goodsall, pointing out the rules of extension of 
fistulous tracts, says : " Those in the anterior quadrant pro- 
ceed directly into the anus or rectum, the aperture being found 
almost perpendicularly above the external opening. Those 
in the posterior quadrants extend circularly around the anus, 
and generally open at some point near the posterior com- 



214 DISEASES OF- ANUS, RECTUM, AND SIGMOID 

missure. Subtegumentary fistulas may burrow subcutaneously 
in all directions, because there are no connective-tissue walls 
to obstruct them. Those situated anteriorly are likely to 
extend forward into the perinseum and scrotum or upward 
into the cruroscrotal folds. Those situated posteriorly bur- 
row outward into the buttocks, or upward behind the coccyx 
and sacrum beneath the skin." 




Fig. 70. — Complex fistula. 



It is remarkable to what extent these subcutaneous bur- 
rowings may extend. The subtegumentary fistula so fre- 
quently found associated with pruritus ani is very likely to 
burrow entirely around the external anal orifice just beneath 
the true skin, but rarely extends far out on the buttocks or up 
the perinseum. Chronic cases are likely to have several inter- 
nal openings, but these may be very superficial and not extend 
beneath the fibres of the sphincter. 



ANORECTAL FISTULA 215 

Submuscular fistulse may extend from one ischiorectal 
fossa to the fossa of the opposite side, or into the retrorectal 
space. 

The treatment of complex fistulae consists in the incision 
and thorough drainage of every fistulous tract, or, when very 
superficial they may be excised and sutured immediately. In 
the case of those which open at a remote distance from the 
anus, it would be better to make counter-openings every few 
inches from the external opening, and insert in them drainage- 
tubes ; this method to be continued until within about two inches 
from the anal margin. From this point to the internal open- 
ing, let the fistula be treated as previously recommended in 
complete fistula, by dividing all the intervening tissues between 
the last counter-opening and the internal opening of the fistula. 
This last incision should be treated as previously recommended 
in complete fistula. If any lateral tracts from the main 
fistulous canal exist they should also be opened and drained. 

The condition previously spoken of as watering-pot fistula, 
while not implying a corresponding number of internal open- 
ings (as there is generally only one in such cases), does bear 
some relation to the size of the internal opening, to the con- 
stitutional condition of the patient, and the duration of the 
fistula (Goodsall and Miles, page 117). The internal open- 
ings in these cases are likely to be large, to occur in syphilitic 
patients, and generally indicate a chronic stage of the fistula. 

Fistula with More than One Internal Opening. — 
There may be present two or more, connected with one fistu- 
lous tract, or there may be two, each being connected with 
separate and distinct fistulae. It is possible that the two dis- 
tinct internal openings may have originated independently, 
and yet their tracts may communicate with a tract common to 
both with only one external opening. After the wounds fol- 
lowing these extensive fistulas have healed, if much retraction 
of the rectum, or much incontinence is found, the cicatrices 
may be dissected out, the anus loosened from its new attach- 
ments and brought down and sutured in its normal position. 



216 DISEASES OF ANUS, RECTUM, AND SIGMOID 



COMPLICATIONS ATTENDING AND FOLLOWING OPERATIONS 
FOR FISTULA 

The complications attending and following operations for 
fistula may be immediate or secondary. 

Immediate Complications. — While excessive loss of blood 
following an operation for fistula is an unusual occurrence 
with the efficient means we now have at hand for controlling 
the same, yet in cases where the incisions are very extensive 
and deep a great deal of blood may be lost simply from oozing, 
this, in the weakened condition of many patients, having a 
serious effect and demanding prompt control. 

Let spouting vessels be clamped and ligated at once, and 
the oozing controlled by compression with gauze, either wrung 
out of very hot water or in the dry state. Do this as the 
operation proceeds, and to control this oozing in the final 
dressing I rely upon tight packing, which is allowed to remain 
in from twenty-four to thirty-six hours. 

Hemorrhage is more likely to follow operations done under 
cocain anaesthesia, on account of the temporary contraction 
of the arterioles by the drug, which relax as soon as the effects 
of the drug wear off, and also from the systemic effect of the 
cocain in raising blood-pressure. For that reason, after cocain 
anaesthesia the patient should be kept quiet for several hours. 
For the same reason extensive operations under cocain should 
not be attempted in the office. 

Where there are extensive fistulous tracts about the 
anterior quadrant and in the perinaeum, special precautions 
must be taken against injuring the urethra; a sound intro- 
duced as a guide to avoid wounding the urethra, and any 
undue manipulation, which may result in acute congestion, 
temporary oedema, and constriction of the urethral canal, 
avoided. In packing this wound take care not to use sufficient 
compression to obstruct the urethra and cause retention of 
urine. 



ANORECTAL FISTULA 217 

After restoration to consciousness, following the anaes- 
thetic, if there should be an urgent desire to defecate, it will 
be better not to restrain the patient too long, as it may be due 
to a concealed hemorrhage, which would be made known by 
an evacuation. 

Shock. — This is more likely to follow those operations 
where there has been a considerable loss of blood, or extensive 
cauterization. It can be met by an infusion of normal salt 
solution, and hypodermics of strychnia, digitalin and morphia, 
especially the latter. 

Sepsis. — Notwithstanding the fact that pus is always 
present in these cases, there may be a diffuse periproctitis fol- 
lowing an operation for fistula. This may be due to a rein- 
fection with pus organisms from the fistulous tract, or there 
may be an infection of the freshly-cut surfaces with a more 
virulent pus organism, which has been introduced by the care- 
lessness of the operator. Therefore take every precaution 
against so introducing a pathogenic organism. 

I once had a case of infection by the erysipelas organism, 
through the carelessness of a nurse when the patient had almost 
recovered from the operation for fistula, and was just about to 
be discharged from the hospital. It developed at the seat of 
the operation and soon caused death. 

Of late complications following operation for fistula, one 
of the most annoying is incontinence of faeces. This was for- 
merly more common than now, due, I think, in many cases to 
the prolonged packing of these wounds after the operation. 
As to packing, let it be done principally for the purpose of 
controlling hemorrhage, and keeping the freshly-cut surfaces 
separated for a few days until they have become glazed over; 
after which, the daily separation of the cut surfaces for the 
purpose of irrigating the wound will be sufficient to keep them 
apart. 

The next most frequent cause for incontinence is a diag- 
onal or jagged incision of the external sphincter muscle, result- 
ing in a bad union of the cut ends. Incontinence may also 



218 DISEASES OF ANUS, RECTUM, AND SIGMOID 

result from over-divulsion of the sphincter when associated 
with some form of spinal trouble; in such cases the proper 
muscular tone is never regained. To avoid such an accident 
cut the external sphincter muscle squarely across, and never 
oftener than once during the same operation, if it can possibly 
be avoided. 

Treatment of Incontinence. — Little can be accomplished 
without operative interference. In the opinion of most writers 
on this subject the condition is the result of the separation of 
the fibres of the external sphincter muscle by scar tissue, or 
a complete separation of these fibres, or prolonged packing 
during the process of healing, which results in a sulcus or 
gutter which separates not only the fibres but all of the adjoin- 
ing tissues. Thus the muscle in contracting pulls the sides 
of this sulcus farther apart and rather increases than lessens 
the opening. The loss in the continuity of the sphincter muscle 
being the cause of the trouble, the remedy lies in the restitu- 
tion of the same as nearly as possible. The success of this 
procedure depends upon the amount of its destruction during 
the operation, the extent of the subsequent sloughing, and the 
length of time that has elapsed since the operation, which will 
determine the amount of muscular atrophy. 

The method generally advised is to take a V- or wedge- 
shaped piece out of the obliquely-united muscle, which should 
also include the scar tissue of the wound (Fig. 71). 

The technic is as follows : First incise the mucous mem- 
brane at the skin margin, parallel to the fibres of the sphincter 
muscle ; then carefully dissect it up until it is above the bottom 
of the sulcus and the underlying scar tissue ; this is held out 
of the way until the ends of the muscle have been sutured, 
when it is brought down and sutured to the internal margin 
of the wound. The wedge piece of scar tissue is now removed 
down to the healthy tissue, the apex of which should be 
internal, with its base external. This divides the muscle at 
right angles with the plane of its fibres, shortens the muscle, 
and permits an end-to-end approximation of its fibres. They 



ANORECTAL FISTULA 219 

should be secured in this position, first, by interrupted silk 
sutures, and next by a silver-wire brace suture, which is passed 
about half an inch outside the silk suture on one side, and 
carried beneath the floor of the incision out on the opposite 
side, half an inch beyond the silk sutures ; it is intended to 
relieve the tension of the latter. The ends should be drawn 
together, and secured over a piece of sterile gauze. 



&% 



Fig. 71. — Showing V-shaped incision to be made for removing scar tissue before approxi- 
mating the ends of the sphincter ani. 

The wound is now dressed with sterile gauze, the buttocks 
strapped with adhesive strips, and a T-bandage applied to 
hold the dressings in position. 

Keep the patient in bed until the seventh day; his bowels 
to be confined for about six days, during which time milk 
should be positively forbidden, and the diet restricted to eggs, 
a small portion of fresh meat, and only a sufficient amount of 
fruits and green vegetables to prevent the fecal matter from 
packing in scybalous masses. The day before the bowels are 
to be moved, olive oil should be administered in half-ounce 



220 DISEASES OF ANUS, RECTUM, AND SIGMOID 

doses at eleven, four, and nine o'clock, the object being to 
soften the fecal matter. On the following day, half-ounce 
doses of castor oil should be given every four hours, until 
the bowels are moved. When the desire for a movement 
arises, about four ounces of cotton-seed oil should be injected 
into the rectum. 

Should any portion of the wound become infected, it 
should be laid open immediately, washed out thoroughly with 
peroxide of hydrogen and well drained, but unless it involves 
the entire wound it will not be necessary to open the latter 
throughout. If the sphincter has been divided on both sides 
of the anus, it will be better to restore it on each side at sepa- 
rate sittings. 

When the muscular fibres have become atrophied from 
long disuse, following the operation for fistula, or from very 
extensive destruction of the sphincter, it is very difficult to 
restore continence, except in a partial manner by narrowing 
the anal outlet. In such a condition Dr. Chetwood, of New 
York City, has succeeded in restoring continence by a very 
ingenious plastic operation. This consists in making a semi- 
circular incision, extending from one tuberosity to the other, 
its convexity being directed backward over the coccyx, and 
a little beyond it (Fig. 72). The flap is turned down and 
dissected forward to a point anterior to and around the anus, 
but the skin is not separated from the anal margin. This 
exposes the lower end of the rectum and the edges of the 
glutei muscle. A ribbon-shaped piece of muscular tissue 
about one-fourth of an inch in breadth and one-sixteenth of 
an inch in thickness is then dissected from the edges of the 
glutsei muscles on each side, allowing the end to remain 
attached to the coccyx. These ribbon-shaped bands are crossed 
to its opposite side and in so doing are carried beneath the 
ligamentous attachment of the anus to the coccyx and made 
to encircle the anus; where the two are united by chromicized 
cat-gut (Fig. 73). A very small remnant of the sphincter 
w^as found on each side of the rectum, to which the muscular 



ANORECTAL FISTULA 



221 



strips from the glutei muscles were attached by sutures. The 
skin flap is then sutured back in position and the wound closed 
with aseptic precautions. There was some slight sloughing in 
the edges of the wound, otherwise it closed without being 
attended with any complications. The patient's control over 
his fecal discharges was established at once and one year 
later it was sufficient to control them under all conditions. 




Fig. 72. — Chetwood's operation for fecal incontinence — first step. (Tuttle.) 

If for any reason this method could not be used, or failed 
to give the desired result, it would be justifiable to perform a 
left inguinal colostomy, with the recent recommendation of 
bringing the bowel out beneath a loop of the internal oblique, 
through an incision in the external oblique muscle. This 
gives the patient very excellent control over his fecal dis- 
charges, and where supplemented by the compress and receiver 
(Fig. 119) is very satisfactory. 



222 DISEASES OF A^X T S, RECTUM, AND SIGMOID 

Sometimes internal hemorrhoids, or the mucous membrane 
itself, may protrude into the fistulous wound and thus retard 
healing. They should be removed, if observed at the time 
of operation, but if then overlooked should be removed at any 
subsequent time interference with the healing- of the wound 
is noted. I have never seen any bad results following their 
removal at the time of operation for the fistula, but it is prob- 
ably safer to remove them by the clamp and cautery if there 
is much suppuration going on in the fistulous tract. 

When removed subsequently to the operation for fistula, it 
may be done under cocain anaesthesia. 



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Fig. 73. — Chetwood's operation — second step. (Tuttle.) 



Protracted Suppuration follozi'-ing the Operation for 
Fistula. — This sometimes happens on account of the depleted 
condition of the patient, or where there is syphilis, Bright's 
disease, diabetes, cardiac disease, or pronounced anaemia. 
These conditions should be recognized before the operation 
and influence the extent of cutting to be done, no more than 
is absolutely necessary being done. 

If the superficial edges of the wound should unite pre- 
maturely, they should be separated at once, and the wound 
made to heal from the bottom. 



ANORECTAL FISTULA 223 

Complicated Fistulae. — These originate in bone or adjoin- 
ing organs, and open into the rectum or around the anal 
margin. 

Fistula that Originate in Diseased Bone. — In dis- 
ease of the pelvic bones, or the spinal vertebra, from any cause 
that gives rise to suppuration, the pus is likely to burrow 
between the sheaths of the muscles and layers of fascia, until 
finally it gravitates to the most dependent position, which in 
this instance is in or around" the rectum. 

The point at which the pus accumulates and which finally 
becomes the abscess cavity is not attended with the acute 
inflammatory symptoms found in abscesses originating in this 
region, such as chill, local redness, induration, and pain, but 
develops as a cold abscess, with a dull, heavy aching in the 
pelvis, and at first with an indistinct swelling, which is not 
attended with induration. These collections of pus generally 
give rise to so little inconvenience that they are likely to open 
spontaneously, especially into the rectum, before the patient 
seeks surgical advice. These openings may be anywhere in 
the rectum, on the perinseum, or on the buttocks. While they 
are likely to burrow ■ into the rectal space that is nearest to 
the diseased bone or organ in which they originate, such is 
not always the case, so that the location of the spontaneous 
opening does not always give a clue to the origin of the 
primary trouble. The extent to which pus may burrow in 
certain of these cases is very surprising. 

Diagnosis. — Prompt recognition of the fact that the abscess 
or fistulous tract in question originates in diseased bone, or in 
an adjoining organ, and not in the perianal or perirectal tissues, 
is very important, as it has an important bearing upon the 
course of the treatment to be pursued. Often in such cases 
it will either be impossible to reach its source or impracticable 
to remove it if it can be reached; therefore the treatment 
consists largely in giving free drainage at the most dependent 
part, followed by frequent antiseptic irrigations. If the dis- 
eased bone can be reached, and removed by scraping, it should 



224 DISEASES OF ANUS, RECTUM, AND SIGMOID 

be done by all means, and better through an opening- directly 
over the seat of the trouble; but this must not interfere with 
enlarging the lower opening to give free drainage to the 
fistulous tract. These surgical means of relief should be fol- 
lowed by general supporting treatment. The sphincter muscle 
should always be preserved intact if possible, even though an 
internal opening from the fistulous tract into the rectum should 
be found; in such a case, either the internal opening must be 
enlarged, or, much better, tap the fistulous tract by an opening 
from the outside, but do not cut through the intervening 
tissues so as to divide the sphincter. 

I have recently been using the tuberculin test for diag- 
nostic purposes with satisfactory results in all cases of fistula 
in ano, after the method recommended by Louis Hamman 
and Samuel Wolman. I use the conjunctival and the cuta- 
neous test simultaneously; if results are negative, then the 
subcutaneous test. I instil one drop of I per cent, of old 
tuberculin (Calmette's preparation) into the eye and make 
several scarifications in the back of the arm, on which I drop 
several drops of the tuberculin solution and after four or five 
minutes strap a piece of gauze over the scarification. If 
there is any reaction it will show by the following day. If 
both methods are negative and I desire to make my diagnosis 
still more positive I then resort to the subcutaneous method. 
If this is also negative and there are no general symptoms to 
indicate it, I feel fairly sure of having neither a tubercular 
fistula nor subject to deal with. As Hamman and Wolman 
have very properly said, " These tests can never replace in 
the slightest degree a carefully taken history of a w r ell made 
examination; they are aids and nothing more." 

Fistulas Originating in Other Organs. — Fistulse origi- 
nating in or connected with other organs, and opening into 
the rectum or around the anal margin, are very properly classi- 
fied by the name of the organ in which they originate ; as, for 
instance, urinary or genital. The first or urinary is always 
connected with some part of the urinary tract, as with the 



ANORECTAL FISTULA 225 

urethra, bladder, or ureter. The first two appear almost 
exclusively in males, owing to the fact that the urethra and 
bladder in the female are separated from the rectum by the 
vagina and uterus. It is, however, possible to have a vesico- 
rectal fistula in a female. The genital fistulse are mostly found 
in women. Occasionally a superficial subtegumentary fistula 
may be found burrowing on the surface of the scrotum. 
Abscesses occurring in the prostate or Cowper's glands may 
break through into the rectum without communicating with 
the urinary tract, and although they form blind internal fistulae 
(before described), yet strictly speaking they are rectogenital 
fistulse, unless they open into the urethra at a later period. 

Urinary Fistulae. — These may be divided into perineal, 
recto-urethral, recto-ureteral, and rectovesical. 

Perineal Fistula. — Fistulse originating in the urethra 
are frequently found opening on the perinaeum and occasion- 
ally even surrounding the rectum before doing so. They 
simulate so closely the anorectal fistula that it is well for the 
operator to bear such a possibility in mind. They usually 
originate from disease in the bulbous portion of the urethra, 
or in Cowper's glands. As these form the anterior boundary 
of the urogenital triangle and are included between the layers 
of the deep and superficial fascia, it is easy to understand how 
extravasated urine or pus will find its way through this tri- 
angle, and thence backward beneath the skin and perineal 
fascia around the anus. In these cases there is nearly always 
a history of urethral disease, such as gonorrhoea and stricture. 
There is also likely to be an absence of the usual symptoms 
attending an anorectal abscess. The presence of urine in the 
discharge from the fistulous tract, or the odor from the 
same, may give rise to suspicion of its true character, which 
may be confirmed by compression of the urethra while in the 
act of voiding urine ; then by watching the fistulous opening, 
urine will be seen to flow from it. Another method consists 
in giving the patient a small capsule of methylene blue, which 

15 



226 DISEASES OF ANUS, RECTUM, AND SIGMOID 

will stain the urine in the course of a few hours, and can be 
recognized at the opening of the fistulous tract if it is con- 
nected with the urethra. 

Treatment. — This consists in a simple incision, and a 
laying open of the fistulous tract to a point just beneath its 
connection with the urethra, attention being given to the treat- 
ment of the primary urethral disease, especially to the dilata- 
tion of any stricture that may exist, and to making the urine 
as non-irritating and aseptic as possible. 

Recto-urethral Fistula. — This consists of a fistulous 
tract between the urethra and the rectum. It always involves 
the membranous or prostatic portion of the urethra, and as a 
rule the opening into the rectum is above the external sphincter. 
This condition is rare, and as it almost invariably has its 
origin in the urethra properly belongs to the genito-urinary 
surgeon. For the same reason it might be proper to designate 
the condition as urethrorectal fistula. 

Etiology. — The causes apt to produce this condition may 
be either traumatic or pathologic. Of the former the most 
frequent causes are punctures through the urethra by sounds 
or catheters. It is not necessary that complete penetration 
take place in order that a fistula may result. If the urethral 
wall be only slightly torn, an abscess is almost sure to follow 
from the extravasation of the urine, in which case it will likely 
break into the rectum, this being the direction of least resist- 
ance. The operations of prostatectotomy or internal ure- 
throtomy may each result in the formation of a fistula between 
the urethra and rectum ; also traumatism of the perinseum, 
which is followed by extensive sloughing. Among the other 
causes of recto-urethral fistula are cancer of the rectum or 
prostate, tubercular, syphilitic, or simple ulceration of the 
rectum, and calculi of the prostatic or membranous urethra. 

Congenital recto-urethral fistulse are not included among 
the above, as they belong to the class of malformations. 

Diagnosis.— The characteristic symptoms upon which the 
diagnosis for recto-urethral fistula depends are the passage 



ANORECTAL FISTULA 227 

of urine into the rectum, or escape of gas and intestinal con- 
tents into the urethra; the one in which the opening is on the 
higher plane will determine the character of the abnormal dis- 
charge. The presence of urine in the rectum is much more 
frequent than the presence of gas or fecal matter in the urine, 
because the prevailing diseases which give rise to this con- 
dition originate in the urethra, and its plane is on a higher 
level than the opening into the rectum generally. When the 
fecal contents do pass into the urethra, the opening at the 
rectal end of the fistulous tract is always large. When the 
urine passes into the rectum, which is of course only at the 
time of micturition, it is generally expelled immediately, 
although sometimes there is a tolerance of the urine by the 
rectomucous membrane, and a retention of it until the next 
act of defecation. In these cases spermatozoa may also be 
found in the urine which has passed into the rectum. 

When either the urine passes into the rectum or the fecal 
matter passes into the urethra, they set up inflammatory symp- 
toms and there is generally- diarrhoea or frequent micturition. 
According to Richet, the sphincter muscle loses its control in 
these cases, and Legueu states that the skin upon the buttocks 
and perinseum becomes excoriated. 

Usually the rectal opening can be felt by digital examina- 
tion, and where this is large enough to admit the tip of the 
finger a sound introduced through the urethra can be felt. By 
the aid of a single-bladed speculum, the rectal opening can be 
exposed and a probe passed into it. 

Recto-urethral fistula can be differentiated from the recto- 
vesical, by the fact that in the latter the urine flows into the 
rectum nearly continuously. 

Where recto-urethral fistulse result from operative pro- 
cedures the prognosis is favorable. 

Treatment. — There is little tendency to heal spontaneously 
in cases resulting from diseased conditions, nor is the success . 
of tentative measures sufficient to warrant their use except in 
cases following operations, those due to traumatism and those 



228 DISEASES OF ANUS, RECTUM, AND SIGMOID 

which follow acute and circumscribed abscesses. These may 
be treated by antiseptic irrigations, stimulating applications, 
and catheterization of the parts. 

Of the different operative procedures which have been 
recommended for the relief of the more chronic and aggra- 
vated cases, and they have been numerous, the author recom- 
mends that advised by Hugh H. Young, of Baltimore, 
Maryland : 

" After," he says, " trying various methods, as simple 
dilatation of the rectum, division of the anal sphincter and 
laying bare the perineal rectal fistula, closure of rectal fistula 
alone, simultaneous closure of both rectal and urethral fistula, 
with drainage through a catheter in penile urethra, through a 
bulbous urethrotomy, or through the urethral fistula itself, I 
became convinced that it was necessary to remove the neces- 
sity for urination through the urethra, or of drainage through 
the urethra, in order to prevent breaking down of the rectal 
wound. I therefore decided to supply suprapubic drainage 
so that all urine might escape through the suprapubic region 
and the spasmodic efforts of urination be done away with, 
followed by the simultaneous closure of both the rectal and 
urethral fistula through the perinseum. This operation has 
been carried out in three cases with a perfect closure of the 
rectum in each case, and in these same cases there was always 
a breaking down of the rectal wound when the suprapubic 
drainage was not provided. It therefore seems evident that 
the best operation for recto-urethral fistula is preliminary 
suprapubic cystostomy, followed by closure of the rectal and 
urethral fistula through the perinceum. 

" The operation is best done in the following manner : 
The patient is placed in the Trendelenburg position, and the 
bladder filled with fluid through a silver catheter. An incision 
I 1 /*, inches long is made in the skin, the recti muscles sepa- 
rated, and the anterior surface of the bladder exposed after 
pushing back the peritoneum. Two silk sutures are inserted 



ANORECTAL FISTULA 229 

into the bladder wall not too close to the prostatovesical junc- 
ture and the bladder incised, a long drainage-tube about the 
size of the little finger is then inserted and the bladder closed 
tightly around it with cat-gut. The tube should not project 
more than 2 cm. into the bladder, so that its end does not 
impinge against the prostatic orifice or trigone (the opening 
high up on the bladder wall having been made so for the same 
reason). A small gauze wick is placed in the prevesical space 
and the recti muscles and skin are partially approximated with 
interrupted sutures of silver. The patient is then placed in 
the lithotomy position, and a probe inserted through the fistula 
into the rectum and one also (if possible) into the bladder. 
A sound is inserted in the urethra. Incisions are then made in 
the perinseum along the line of the operative cicatrix, and the 
scar tissue around the fistula excised carefully as far as the 
urethra and rectum. The edges of the two fistulse are then 
excised until healthy tissue is obtained. 

" The rectum is closed first with interrupted sutures of 
fine silk, the first layer through the submucosa and turning in 
the mucous membrane, but not including it. The second layer 
includes the musculosa and is also of silk. The third layer is 
of cat-gut and includes additional musculosa and perirectal 
muscle, so as to cover in the previous sutures with a thick 
pad of muscle. Attention is then directed to the urethral 
fistula, which is closed with one or two layers of interrupted 
cat-gut, or very fine silk sutures. (The rectal wound is the 
most important. There is usually less tissue to approximate 
around the urethra.) Before closing the skin a light pack of 
gauze is placed in the rectal and urethral wounds and the 
levator muscle drawn well together over the rectum with two 
or three sutures of cat-gut. The skin is partially closed with 
interrupted cat-gut, the gauze wick emerging from the anterior 
angle. Before leaving the table the bladder is washed free of 
blood by a to-and-fro irrigation through the suprapubic tube. 
After the patient is returned to the bed the suprapubic tube 



230 DISEASES OF ANUS, RECTUM, AND SIGMOID 

is placed in a bottle on the floor with the end immersed in 
water so that siphonage will be secured. (This does away 
with the necessity of a Cathcart apparatus.) 

" The bowels should be kept quiet for at least six days, 
If they have been thoroughly emptied two days before opera- 
tion, and the patient has been on milk diet for three days, little 
difficulty is experienced in preventing defecation for a week. 
It is best to give a lead and opium pill for two or three days 
and to confine the patient to liquid diet. At the end of six 
days the bowels are moved with as little straining as possible. 
This is best accomplished by injecting a small amount of oil 
and glycerine into the rectum to be retained, and giving the 
patient an ounce of castor oil by mouth followed two hours 
later by Rochelle salt. In this way successful evacuation of the 
bowels is accomplished with little straining and without the 
necessity of large enemata, which are distinctly objectionable 
(not to say dangerous) after all prostatic operations." 

Rectovesical and Enterovesical Fistulae. — These consist 
of abnormal communications between bladder and rectum, 
and between the bowel above the rectum and the bladder. The 
rectovesical fistula may result from tapping the bladder 
through the rectum, a practice now obsolete; from accidents, 
as bullet wounds, punctures by pointed pieces of iron and 
wood; foreign substances in the rectum; stone in the bladder; 
from operations on the bladder and rectum for malignant 
disease, and from destructive inflammatory processes. Ulcera- 
tion of the bowel, either of the sigmoid or the small intestine, 
especially tubercular or syphilitic in origin, may cause at first 
adhesions with the bladder and then by extensive ulceration 
a fistulous communication between the two. This is much 
more rare than the communication between the rectum and 
bladder, as shown from statistics. Of the eighty-nine cases 
reported of fistulous communication between the bladder, 
rectum, sigmoid and small intestine, in thirty-eight the com- 
munication was with the rectum. (James P. Tuttle, " Dis- 
eases' of the Anus, Rectum, and Pelvic Colon," page 440.) 



ANORECTAL FISTULA 231 

Diagnosis. — When the fistulous opening is between the 
small intestine or the sigmoid and the bladder, the diagnosis is 
made by the presence of fecal matter or gas in the urine ; when 
the communication is between the upper part of the rectum 
and the bladder, it may either be the same or as when the 
opening is in the lower part of the rectum, by the presence of 
urine in the rectum. In the large majority of cases, however, 
the diagnosis will be made by the presence of urine in the 
rectum. The other symptoms will be similar to those pre- 
viously described under rectovesical fistula. 

Symptoms. — Cystitis or proctitis, either the one or the 
other, will always be present, depending upon which receives 
the discharge from the other. Pus and blood may be con- 
tained in the discharges of either, especially if the fistula 
is the result of a pelvirectal abscess or the breaking down of a 
malignant growth. Where the fistulous communication is 
due to either of the latter two causes, the previous symptoms, 
together with the induration attending upon the latter, will 
indicate the primary cause. 

The proctoscope, the sigmoidoscope, and the cystoscope 
will in the large majority of cases enable the surgeon to locate 
the openings into both bladder and bowel, except when in 
the latter the opening is in the small intestine. 

The prognosis is very grave, especially where the fecal 
contents empty into the bladder, where the resulting inflam- 
mation soon extends up through the ureters to the kidneys, 
giving rise to " surgical kidney," the most frequent cause of 
death. In those cases where there is an intervening abscess 
cavity between the two openings the escape of urine and fecal 
matter into this cavity is likely to result in urinary infiltration, 
or burrowing tracts which may perforate the peritoneum 
giving rise to fatal peritonitis, or if they burrow down to the 
buttocks, or around the anus, may result in extensive slough- 
ing and suppuration, which soon results in exhaustion and 
death. 



232 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Treatment. — As the most unfavorable cases are those 
where the fecal contents empty into the bladder, it is obvious 
that the first and most important step is to divert the fecal 
current; this can be accomplished by a temporary artificial 
anus, unless the opening is into the small intestine. If per- 
manent catheterization be associated with the artificial anus, 
the two may result in the spontaneous closure of the fistula. 
If the tract fails to close spontaneously under these conditions, 
if the rectal opening is low down it may be closed by 
making the surrounding surfaces raw, and drawing them 
together with chromicized cat-gut sutures, the same being so 
placed as to invert and approximate the edges of the wound. 
The rectal opening may be too high up to accomplish this by 
merely drawing back the posterior rectal wall, then split the 
same back to the coccyx and extend the rectal end of the 
incision four inches up the rectum in order to allow sufficient 
room to close the rectal opening. Either permanent or 
repeated catheterization should be continued until the wound 
in the rectum has united. 

When the urine is emptied into the rectum the most im- 
portant step is to stop or divert its flow. It would be useless 
to attempt to close the rectal opening when the flow is 
allowed to dam up against the freshly-closed wound in the 
rectum, so in these cases, and also in those resulting from a 
pelvirectal abscess, it is better to make a lateral perineal 
section above the fistulous tract and thus, by dissecting the 
latter, the opening into each may now be curetted and sutured 
from the perineal wound. If a pelvirectal abscess cavity 
exists, it may also be curetted. In either case it is better not 
to close the perineal wound, but keep it drained thoroughly 
and let it close from the bottom by granulation. After sutur- 
ing the openings from the perineal wound, both urine and fecal 
matter should be kept from coming in contact with the fistulous 
openings on the mucous surface of each. 

Now, if the fistulous opening is in the sigmoid or small 
intestine, expose and close the openings by an abdominal sec- 








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ANORECTAL FISTULA 233 

tion and, after opening the abdominal cavity, break up adhe- 
sions between the bladder and the intestines and then suture 
the openings separately, turning in the edges of each opening. 
Where adhesions have been extensive and the peritoneal cover- 
ing of the intestine destroyed by the inflammatory process for 
some distance, it is better to resect that portion of the bowel 
containing the opening, and do an end-to-end anastomosis. 
The wound in the bladder can be turned in and sutured, as 
before recommended. 

The abdominal wound should be drained by a gauze wick 
surrounded by protective tissue, down to the point of the 
. fistulous tract. 

Recto-ureteral Fistula. — Cases are very rare in which the 
ureter opens into the rectum, except in malformations, which 
have already been alluded to. Quite a number of surgeons 
have transplanted the ureter into the rectum after extirpation 
of the bladder for malignant disease. As a rule little can be 
done for the relief of the trouble. 

Rectogenital Fistula. — This term applies to a fistulous 
opening between the rectum and the genital organs. These 
fistulas may be divided into recto-uterine, rectovulvar, and 
rectovaginal varieties. 

Recto-uterine fistulae are very rare, and generally due to 
congenital malformations, although occasionally existing in 
connection with malignant growths, which have involved both 
organs and have then broken down. Thomas Cullen has 
reported one such case in his work on " Carcinoma of the 
Uterus," page 268 (Fig. 74), and James P. Tuttle another in 
his work on " Diseases of the Anus, Rectum, and Pelvic 
Colon," page 446. In the latter cases, if the malignant growth 
is inoperable (almost invariably the rule), and when so 
extensive as to bring about this communication between the 
two canals, nothing can be done. The treatment of those 
resulting from congenital malformations has already been 
given. 



234 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Rectovulvar Fistula. — Here the fistulous tract extends 
from the rectum to the vulva, anterior to the hymen, and is 
generally the result of trauma, or infection with suppuration 
of the glands of Bartholin. When it originates in the glands 
of Bartholin, especially from specific infection, it may occur 
simultaneously on both sides. With both sides affected, if 
the abscess is not promptly opened and drained it is likely 
to burrow backward on one side of the perineal raphe and 
open into the anal canal on the same side, or possibly open 
into the ischiorectal fossa. 

One or more openings may be found and almost cer- 
tainly two, if both sides are affected simultaneously. If seen 
before the abscess ruptures the swelling of the labia with the 
attending pain will indicate the character of the trouble; if 
seen after the fistulous tract has formed, the discharge of 
pus from the anus will lead to an examination which will 
reveal the true state of affairs. There will also be a dis- 
charge from the vulva, but as it is so likely to be confounded 
with a leucorrhceal discharge little attention is paid to it. 

The vulvar opening is found in one or both labia, just 
within the vulva in front of the hymen. 

Treatment. — There is always risk of destroying or inter- 
fering seriously with the perineal body, so as a rule the open 
incision as recommended in anorectal fistula had better not 
be practised here unless for special reasons, but in its stead 
excision with immediate suture of the fistula. If there should 
be two tracts they may be excised at different times, or if not 
attended with too much loss of tissue they may both be done 
at the same time and through one skin incision. In excising 
these tracts it is important to secure accurate apposition of 
the muscular tissue ; therefore, in making the incision, as each 
muscle is cut its ends should be grasped and fixed until the 
wound is ready to be closed, when the cut ends should be 
replaced in apposition. 



ANORECTAL FISTULA 235 

Rectovaginal Fistula. — This consists in an abnormal open- 
ing between the rectum and vagina proper and is the most 
frequent of all complicated fistulse. It is due to a variety of 
causes : submucous rupture of the rectovaginal septum during 
labor; sloughing of the same due to prolonged pressure by 
the fetal head, or sloughing from any cause, either of the 
rectum or vagina; syphilitic ulceration with or without stric- 
ture ; carcinoma of rectum or vagina ; sharp-pointed foreign 
bodies in the rectum ; abscesses developing in the septum from 
any cause; pelvirectal abscesses, the pus from which may 
burrow down and open in both canals ; tubercular ulceration 
of the rectum is rarely so extensive as to involve the vagina. 

Symptoms. — In the majority of cases either the fistulous 
tract has formed when the surgeon is called in, or the patient 
is under the care of the surgeon for the primary trouble when 
the fistula forms. The symptoms are those induced by the 
primary trouble. When the fistula has formed, the charac- 
teristic symptom is the escape of gas and fecal matter into 
the vagina during the act of defecation, and resulting vagini- 
tis with leucorrhcea. 

The opening being low down in the rectum it can readily 
be seen by the aid of a single-bladed speculum, or can be 
viewed in a similar manner from the vaginal side, when a 
probe can be passed through it. 

Even where an examination fails to demonstrate the open- 
ing on account of its valve-like character, the passage of gas 
through the vagina is sufficient evidence that the false passage 
exists. 

Treatment. — Cauterization and other local applications, 
combined with prolonged constipation and frequent irriga- 
tions from the vaginal side, succeed in healing a very limited 
number. In a large majority operative measures are neces- 
sary, and even these have to be repeated several times in a 
certain number of cases. 



236 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Doubtless the chief obstacle to be encountered in healing 
is the liability of reinfection from the rectal side, so let this 
be the chief point of attack. In order to secure the necessary 
aseptic conditions, it is better to thoroughly prepare the rectal 
mucous membrane for twenty-four hours prior to operation, 
and to combine with this the administration of intestinal anti- 
septics by the mouth. When the opening into the rectum is 
high up the difficulties attending its closure are very much 
enhanced and it mav be necessary to make an incision through 




Fig. 75. — Lauenstein's operation for recto-vaginal fistula. (Tuttle.) 



the posterior commissure, but the conditions do not justify 
extending this to include a Kraske operation. When the 
opening is small and low down, it may only be necessary to 
freshen the rectal opening and close it by sutures, but when 
large and especially when some distance above the anus, an 
operation involving the vagina and the perinaeum will be 
necessary. 

Operation. — The simplest is that advised by Lauenstein 
(Fig. 75), which consists in denuding the fistulous tract 
from the vaginal surface down to the rectal mucous mem- 



ANORECTAL FISTULA 237 

brane; stitches being then introduced from the vaginal side, 
should include all the tissues of the rectovaginal septum down 
to the rectal mucous membrane, and the wound is thus closed. 
The sutures should be of silver wire, and the edges of the 
wound must be accurately approximated. The opening in 
the rectal mucous membrane is left open. After the wound 
is closed the sphincter should be stretched, a rectal tube intro- 
duced and the bow : els constipated by an opiate. 

Various other operations have been devised for closing 
rectovaginal fistulae, but that just given meets the demand of 
any average case, opening low down in the rectum. In more 
aggravated ones and those opening high up in the rectum, 
especially if associated with a partial rupture of the perinaeum, 
I advise : 

Complete excision of the fistulous tract combined with 
perineorrhaphy, using the technic suggested by James P. Tuttle 
in his " Diseases of the Anus, Rectum, and Pelvic Colon," 
page 453, as follows : The sphincter muscle is thoroughly 
but gently stretched ; the perinaeum then completely incised 
from the vagina into the rectum up to but not including the 
fistula; a probe is passed through the fistula, and the latter, 
together with all its cicatricial tissue, dissected out en masse. 
The mucous membrane of the rectum is trimmed off from the 
edges of the wound for about half an inch up to the level of 
the fistulous opening, and above this loosened from its attach- 
ments until it can be brought down to the margin of the 
anus; the perineal septum brought together clown to and 
including the sphincter muscle, with a continuous chromicized 
cat-gut suture. Three or four deep silver-wire sutures are 
then passed through the perinaeum, after the manner of 
Emmet. Before the latter are fastened, the mucous flap in the 
rectum is brought down and sutured to the skin at the margin 
of the anus (Fig. j6) ; the wire sutures drawn together and 
made fast by twisting or by perforated shot, and finally the 
eds;es of the mucous membrane in the vagina sutured with 



238 DISEASES OF ANUS, RECTUM, AND SIGMOID 

plain cat-gut and sealed over with iodoformized collodium. 
The operation consists in doing practically a Whitehead opera- 
tion upon the anterior wall of the rectum, combined with a 
complete perineorrhaphy. The mucous flap closes all com- 
munication between the rectum and the perineal wound, and 
thus protects the latter from fecal and gaseous passages. A 




vw/ 



Fig. 76. — Closure of recto-vaginal fistula, showing mucous flap brought outside of rectum 
and sutured to the skin. (Tuttle.) 



small drainage-tube is placed in the rectum to facilitate the 
escape of gas, and the patient's bowels constipated for six or 
seven days. After this period injections of oil and glycerin 
may be given to soften the fecal materials, but under no cir- 
cumstances, except of real danger to the life of the patient, 
should a purgative be given until the hard fecal accumula- 
tions have been removed or softened. The wire sutures are 



ANORECTAL FISTULA 239 

removed on the eighth clay. In seven cases clone by this 
method not a single failure occurred and I personally have 
also had excellent success with this method. 

The extensive destruction of tissue which attends a certain 
number of these cases makes it impossible to restore the rectal 
wall as recommended above without causing a certain amount 
of stricture of the rectum. 



CHAPTER X 
HEMORRHOIDS 

The peculiar arrangement of the blood-supply of the 
rectum, the erect position of man, and the force of habits 
imposed by civilization combine to make hemorrhoids one 
of the most frequent of all rectal diseases. 

It is among the very earliest ills to which human flesh was 
heir and of which we have any account. So it may be inferred 
that when man became sufficiently civilized to record his 
advancements and achievements, the restricting influences of 
such civilization brought out this weak point in his anatomic 
construction. 

On account of the prevalent misconception with regard to 
the structure of hemorrhoids, I begin their consideration with 
the actual pathological findings, literally defining the actual 
conditions. 

Pathology. — The following is a. record of notes made 
by William H. Welch in examining a series of microscopical 
sections, made by myself, at the Pathological Laboratory of 
the Johns Hopkins University and Hospital, while engaged 
in a pathological study of hemorrhoids: 

Dilatation of veins. 

Accumulation of leucocytes in veins, especially in periphery: also 
of blood-plates with the leucocytes. 

Small-cell infiltration in walls of veins. 

Small-cell infiltration in tissue, diffuse, and in foci. 

Plasma cells in tissue. 

The dilatation of veins seems to be mostly on the side of section 
covered with fiat epithelium (integumental side). Here also 
the connective tissue is denser and of coarser fibres. 

Patches of yellowish-brown pigment indicating old hemorrhages. 

Irregular fibrous thickening of walls of dilated veins. 

Hyaline metamorphosis of venous wall (few nuclei). 

Venous capillaries near epidermis filled with leucocytes (thrombi). 



HEMORRHOIDS 241 

The most extensive dilatation of veins is between epidermis and 

smooth muscle (sphincter) ; not in all sections, however. 
Connective tissue compressed and atrophied by ectasis of veins ; 

epidermis thinned. 
Arteries in places seem to have hypertrophied muscular coats 

and thickened membrana limitans interna. 
Also hypertrophy of muscular coat of some veins, but those most 

dilated appear to have atrophied walls. 
Thick longitudinal bundles of muscles in some veins. 
Endarteritis obliterans. — Thrombi composed of fibrin plates and 

leucocytes in some of the veins. 
It looks sometimes as if the walls of the extensively dilated veins 

were thin and atrophied, and those of partly or not dilated 

veins were inflamed. 
Does inflammation of the venous wall precede the dilatation? 
Does hyaline degeneration or coagulation necrosis of venous wall 

precede the dilatation? 
Calcification in arterial wall. 

It will be seen from the above that not only are changes 
noted in the walls of the veins and arteries, but also in the 
surrounding tissues there are decided changes, such as small- 
cell infiltration with dense and coarse connective-tissue fibres 
in some places, while in others the connective tissue is com- 
pressed and atrophied. 

In old hemorrhoidal nodules there may be organization of 
the thrombi with new growth of connective tissue between 
the vessels so that fibrous nodules or masses of varying con- 
sistence remain. These are liable to become the seat of acute 
inflammation. 

From all of these changes it will be seen that hemorrhoids 
are a kind of tumor formation, resembling mostly angioma 
or fibro-angioma. 

Etiology. — This is not very definitely determined, not- 
withstanding the fact that nearly every disease to which flesh 
is heir has been accused of exerting some influence in the pro- 
duction of this malady. 

Complications. — Besides the reflex conditions of stran- 
gury and dysuria, so commonly associated with inflamed hem- 
orrhoids, there may be other symptoms and also conditions 

16 



242 DISEASES OF ANUS/ RECTUM, AND SIGMOID 

associated with, and even produced by them, in their quiescent 
state. For instance, I have had cases where the patient has 
complained of persistent pain in the back, entirely and per- 
manently relieved by removing- hemorrhoids, and one in 
which there was persistent pain in the instep of the right foot, 
relieved by the same operation. 

Still more interesting are two cases of rheumatism per- 
manently relieved by the removal of the ulcerated hemor- 
rhoids. These were reported to me by C. W. McElfresh, of 
Baltimore. I give only one in full, as the second is practically 
a duplicate. 

Case I. — Mr. E. M., age thirty-nine. Family history 
good; as a child had fairly good health, except all the dis- 
eases of childhood. At the age of twenty-three he began to 
have trouble at stool, protrusion and bleeding after each one. 
About three months afterward he suffered with rheumatism, 
was confined to his bed as much as five or six months each 
year. In 1904, eleven years after his first attack of rheuma- 
tism, he was operated on for the relief of his hemorrhoids. 
He gained nearly twenty pounds in weight in a few months, 
and has never had any return of his rheumatism since, a 
period of five years. 

McElfresh makes a point of the fact that the hemorrhoids 
were ulcerated, thus giving a satisfactory explanation for the 
source of infection causing the rheumatism. 

The conditions tending to produce hemorrhoids may be 
divided into : predisposing and exciting. 

Predisposing Causes. — Among the most potent are habits, 
constitutional conditions, and occupations, those of a sedentary 
character being more active in its production ; age, with 
greater frequency in middle age, and heredity, the latter indi- 
rectly playing" a most important part, not that hemorrhoids 
are directly inherited but a weakened condition of the walls 
of the blood-vessels, especially the veins, which results in dila- 
tation and varicosities and they, in turn, in tissue changes, 



HEMORRHOIDS 243 

facts borne out by the experience of every one who has paid 
special attention to the treatment of this malady. 

Probably the most pronounced predisposing cause is that 
due to man's erect posture, which increases the weight of the 
blood-column in the lower half of the body. The fact also 
that the blood-vessels of the rectum pass through the muscular 
walls of the same without being protected from the effects of 
the muscular fibres in contracting, may be classed as an ana- 
tomic cause, and the absence of valves in the portal vessels 
into which the superior hemorrhoidal vein eventually empties 
adds materially to such predisposing causes. 

Exciting Causes — Constipation. — This is unquestionably 
the most frequent of all exciting causes, not so much on account 
of the irritation resulting from hard and dry masses of fecal 
matter passing through the anal canal as from long-continued 
pressure by these masses on the walls of the rectal vessels 
producing stasis in the venous plexuses, and also on account 
of the great muscular effort necessary to expel these hardened 
masses. The effect on the local blood-pressure of this unusual 
effort in defecation is very much accentuated by the peculiar 
arrangement of the blood-vessels of the rectum — already 
referred to in their passage through the muscular walls of 
the same. The muscular coats of the rectum participate, in 
the contraction of the voluntary muscles during this expulsive 
effort, and in so doing compress the thin walls of the veins 
very much more than they do the resisting ones of the arteries 
in their passage through the muscular coat of the rectum. 
The result is, that arterial blood continues to flow into the 
parts, while venous blood is shut off almost completely from 
entering the inferior mesenteric vein on its return to the portal 
circulation, thus raising the blood-pressure in the superior 
hemorrhoidal veins enormously, and very materially favoring 
dilatation of the venous walls. While we occasionally see 
hemorrhoids unassociated with constipation, even in a minor 
degree, these are the cases that are due to other causes, espe- 
cially an inherited weakness of the venous walls. 



244 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Effect of Cathartics. — Hemorrhoids are frequently 
the result of too strenuous efforts to overcome constipation 
by taking active cathartics, especially those containing aloes 
or podophyllin. 

Diet. — As diet has been mentioned before as a causative 
factor in the production of constipation, the latter in turn may 
produce hemorrhoids. The continued use of alcohol, by 
increasing the blood-pressure and disturbing the functions of 
the intestinal tract, is likely to produce hemorrhoids, or if 
already existing may be aggravated by even a few drinks a 
day. 

Strain. — Thrombotic hemorrhoids are nearly always the 
result of straining at stool, which causes rupture of the intima 
of the vein and this results in the formation of a thrombus. 

Hemorrhoids may also be the result of other pathological 
conditions in the rectum, large intestine, genito-urinary, and 
uterine organs, as ulcerations, stricture of the rectum or 
urethra, displacements of the uterus, procidentia, cystitis, pros- 
tatitis, and urethritis ; also from diseases of the liver, heart, 
and kidneys, owing to the influence such diseases have on the 
portal circulation. 

Varieties. — From time immemorial hemorrhoids have been 
divided into external and internal ; this classification can still 
be used with the addition of mixed hemorrhoids, together with 
their subdivisions. 

External Hemorrhoids. — Those located external to the 
mucocutaneous border-line. 

Internal Hemorrhoids. — Those located above and internal 
mucocutaneous border-line. 

Mixed Hemorrhoids. — Those where both the external and 
internal hemorrhoids exist in the same individual (Fig. yy). 

Subdivisions. — A still further subdivision is as follows : 
External hemorrhoids may be divided into thrombotic, vari- 
cose, and connective-tissue hemorrhoids. 

Thrombotic— These are oval tumors, purplish in color, 
the skin surface over the tumor a little or not at all inflamed; 



HEMORRHOIDS 24,5 

and varying in size from a buck-shot to a walnut (Fig. 78). 
They generally appear suddenly after straining at stool, or 
after very prolonged exercise, and are due to the rupture of 
the intima of the vein and the formation of a thrombus. They 
may be single or multiple, and attended with considerable pain, 
due to distention and pressure, and varying with the extent of 
the same. The clot may be absorbed if not very large; or it 
may become organized, rarely calcified, or infected, break 
down, and form an abscess. This infection generally takes 




Fig. 77. — Mixed hemorrhoids. 

place through hair follicles, or sebaceous glands, on account of 
its close proximity to the surface. 

Treatment. — If the clot is small and does not give rise to 
much annoyance it may be left undisturbed, with some general 
directions for the patient to keep quiet and to have easy 
evacuations. Should there be pain, let it be incised under 
local anaesthesia, the clot turned out and the little cavity gently 
packed for twenty- four hours (these cavities, however, should 
not be closed by immediate suture, as the pain that follows 



246 DISEASES OF ANUS, RECTUM, AND SIGMOID 

will be out of proportion to the benefits derived) ; after which 
it may be treated with antiseptic ointments and encouraged 
to heal as rapidly as possible. The bowels should be kept 
open. 

Should more than one hemorrhoid exist, or one in con- 
nection with hypertrophied tags, remove all at the same time. 

Varicose External Hemorrhoids. — These mean a vari- 
cose condition of the systemic veins surrounding the margin 



■■■■■■ 




Fig. 78. — Thrombotic hemorrhoid with inflamed anal margin. 

of the anus, a condition not apparent until the patient is made 
to bear down and strain, when the dilated vessels become dis- 
tended with blood, showing very plainly as tortuous varicosi- 
ties, or by a general swelling of the parts surrounding the anal 
margin. It is a very common condition in persons who are 
subject to chronic constipation. 

There may be very little increase in the connective tissue 
in this form of hemorrhoids, unless they have continued for a 



HEMORRHOIDS 247 

long time, or have been subject to acute attacks of inflamma- 
tion. These develop, as a rule, very slowly, are not attended 
with any pain, nor do they interfere with the action of: the 
bowels. The swelling attending them from distention is uni- 
form and not lobulated. It is this form of hemorrhoids that 
are peculiarly liable to the formation of small multiple thrombi, 
which are the principal cause of the inflammatory attacks to 
which they are subject. 

Treatment. — Little can be accomplished in the treatment 
of these hemorrhoids except operative measures, nor need the 
latter be undertaken, unless inflammation, the result of mul- 
tiple thrombi, sets in. Until this occurs some general direc- 
tions with regard to the regularity of fecal movements, not 
sitting long at stool, avoiding long standing, and stretching 
the sphincter when spasmodically contracted, are about all that 
can be done to palliate this trouble. 

Operation. — When it becomes necessary to operate on this 
form, if not associated with internal hemorrhoids (which, 
however, is very rare), take out two or three transverse 
elliptical pieces of skin on each side of the rectum, with its 
subjacent tissue and varicose vessels, and dissect out the vari- 
cose vessels from under the remaining flaps. Take care not 
to let the incision extend beyond the mucocutaneous line. . 
Wash the wound off with a solution of i to iooo bichloride 
of mercury, and apply a compress of sterile gauze tightly to 
the perinaeum. These should be renewed several times daily 
and the bowels should be confined for three or four days. 

Connective-Tissue Hemorrhoids. — These may result 
from an acutely inflamed hemorrhoid after the inflammation 
and swelling have subsided, during which time hypertrophy 
of the connective tissue and of the skin takes place, or from 
some chronic inflammation around the anal margin. They 
are composed of hypertrophied skin, connective and mucocu- 
taneous tissue around the anal margin. When not inflamed, 
they appear as thin folds of redundant skin and do little if any 



248 DISEASES OF ANUS, RECTUM, AND SIGMOID 

harm, except interfering with cleanliness; they are easily 
irritated and inflamed, and then give rise to pain and dis- 
comfort. 

While existing sometimes entirely independent of any 
rectal trouble within, yet they are frequently associated with 
stricture of the rectum and specific ulceration of the same, 
in fact, any chronic irritating discharge from the rectum may 
give rise to them. They may be single, or multiple; thin, or 
thick; pedunculated, or broad at their base. 

Treatment. — Unless inflamed, or associated with pruritus 
ani, they should not be disturbed, but when they are, they 
should be snipped off with scissors ; especially should this be 
done when there is any suspicion of their being the exciting 
cause of pruritus ani. Do this under cocain anaesthesia, and 
the bleeding can be controlled by pressure. 

Internal Hemorrhoids. — These may be divided into capil- 
lary, varicose, and thrombotic hemorrhoids ; merely successive 
stages of a complete internal hemorrhoidal tumor. 

Capillary Hemorrhoids. — This variety consists of dila- 
tation of the capillaries in the mucous membrane just above 
the sphincter, yet showing very little increase in the connective- 
tissue elements. It is the first stage in the development of 
internal hemorrhoids, and if allowed to continue they will 
almost certainly develop into the varicose variety, with the 
usual increase of connective tissue. 

Symptoms. — Bleeding; sometimes very profuse and always 
easily excited. Upon examination there will be found a rasp- 
berry-like tumor just above the internal sphincter ; it will 
generally be necessary to use the single-bladed speculum in 
order to get a view of it, unless the sphincter is very much 
relaxed. 

Varicose Internal Hemorrhoids. — In addition to the 
above conditions there is a much greater dilatation of the 
veins, with an increase in the interstitial tissue and the forma- 
tion of a true hemorrhoidal tumor. 



HEMORRHOIDS 249 

Thrombotic Internal Hemorrhoids. — This is the con- 
dition existing in varicose hemorrhoids, plus the formation of 
thrombi in the vessels. The symptoms in both of these latter 
varieties are : a decided tumor formation with or without 
bleeding, which as a rule is only occasional, and only some- 
times excessive ; the former is not likely to be painful, unless 
acutely inflamed ; the latter is very painful, because the forma- 
tion of thrombi is attended with and followed by inflamma- 
tory symptoms. These tumors may or may not protrude 
from the anal margin ; as a rule, they only protrude at the 
time of having a stool ; but when they become inflamed and 
swollen, or after having existed in a quiescent state for a 
long time and the sphincter becomes relaxed, they are likely 
to protrude upon the slightest provocation. After they have 
protruded for some little time, the mucous surfaces become 
eroded and denuded of their epithelial covering. They are 
globular in shape, seldom pedunculated, end abruptly at the 
white line of Hilton, unless associated with external hemor- 
rhoids, and even when they are this line marks the division 
between the two. When multiple, there is nearly always a 
longitudinal line of division between the two, corresponding 
with the sulci between the columns of Morgagni. This is one 
of the distinguishing features between internal hemorrhoids 
and prolapse of the rectum. 

Mixed Hemorrhoids. — Either of the varieties of external 
or internal hemorrhoids may coexist in the same individual, 
and the white line of Hilton is the dividing line between the 
two. It is at this line that the connective tissue is denser, the 
mucous membrane more closely adherent to the muscular 
walls, and the vascular supply most limited; therefore, it is 
very seldom that any hemorrhoids ever involve this line, and 
then only when internal hemorrhoids have existed for some 
time and by their pressure downward have gradually raised 
the mucous membrane and distended the connective tissue. It 
is when the hemorrhoids have passed this line that free anas- 



250 DISEASES OF ANUS, RECTUM, AND SIGMOID 

tomosis is established between the superior and inferior hem- 
orrhoidal veins, or between the portal and systemic vessels. 

These hemorrhoids are covered by both mucous and muco- 
cutaneous tissue, and are as previously described complete 
hemorrhoidal tumors, of both the external and internal 
varieties. 

Any of the varieties of internal hemorrhoids (or where 
the internal exist in connection with external, as in mixed 
hemorrhoids) may become strangulated, either by the pro- 
lapsed mass being grasped by a spasmodic sphincter, or by 
the circulation in the internal hemorrhoids being interfered 
with and blocked by inflammatory processes. In either case 
the hemorrhoids become very much swollen and enlarged in 
consequence of this obstruction to their circulation, and will 
not return above the sphincter of themselves, nor are they 
easily replaced. 

If the strangulation has not existed for any length of time, 
and the patient refuses to be operated upon, they may be 
returned into the rectum; first, by placing the patient in the 
knee-chest position, so that the hips may be well elevated, or 
better still, in " the Mathews-Haines position " ; then, anoint- 
ing the hemorrhoids well with vaselin, the surgeon may by 
steady but gentle pressure with the four fingers return them. 
If he fails to do so by this means, then a general anaesthetic 
may be administered, when they can be readily returned. 

If the patient agrees to an operation, deal with these as with 
other internal hemorrhoids, regardless of their strangulated 
condition, unless they have become gangrenous, in which case 
they had better be excised, the bleeding vessels controlled by 
buried ligatures, and the wound left to heal by granulation. 
Take special care during the process of healing to prevent a 
secondary hemorrhage, by keeping the patient perfectly quiet 
and in a recumbent position for six or eight days, or until the 
wound presents a perfectly healthy, granulating appearance. 
As soon as the hemorrhoids are excised and the bleeding con- 



HEMORRHOIDS 



251 



trolled the fresh surfaces should be cauterized, either with a 
hot iron or pure carbolic acid, to prevent infection from the 
septic conditions. Under no condition should the gangrenous 
mass be left to slough away. 

If inflamed conditions exist and the patient declines opera- 
tion, the internal hemorrhoids should be returned and ice 
applied to the parts. The following ointment may be intro- 
duced into the rectum by a pile-pipe (Fig. 79), or a collapsible 
metallic tube with a nozzle (Fig-. 80) : 

B — Pulv. opii gr. x 

Ext. hyoscyamus gr. xii 

Ext. hamamelis virg 3ii 

Vaselin q.s. Si 




Fig. 79. — Pile ointment pipe. 




Fig. 8o- — Collapsible metallic tube. 

The above quantity of ointment should serve for about twelve 
applications, making an application every three or four hours. 

The use of alcoholic drinks should be interdicted. 

Treatment of Internal Hemorrhoids. — Palliative 
Treatment. — When these are not inflamed, much can be done 
to relieve the annoyance by regulating the evacuations ; avoid- 
ing excessive action ; securing the proper consistency of stools ; 
replacing the tumors immediately after stool, after which the 
patient should lie down for half an hour; and if there is bleed- 
ing it should be controlled by styptics. Where there is 



252 DISEASES OF ANUS, RECTUM, AND SIGMOID 

considerable irritability, with spasmodic contraction of the 
sphincter, much relief will be afforded by dilating the sphinc- 
ter, which can be done satisfactorily, under local anaesthesia, 
as before advised. 

Operative Treatment. — There have been numerous opera- 
tive procedures suggested and practised for the removal of 
hemorrhoids, but I refer only to those in general use at the 
present time, and include the injection method and electrolysis, 
although strictly speaking they cannot be classified as opera- 
tions. 

Injection Method. — Here is the technic of Collier F. 
Martin, of Philadelphia, Penna., probably one of its most 
ardent advocates in this country, and who with his father, 



Fig. 8 i. — Collier F. Martin's Conical Speculum. 

Dr. Robert W. Martin, has practised it since 1876; the latter 
worked out their present technic in a most careful and judi- 
cious manner, as seen by referring to some unpublished notes 
by him contained in a paper written by his son, Dr. Collier 
F. Martin, and published in American Medicine, Vol. viii, No. 
9, pages 3 6 5-37 , August 27, 1904. 

Their first recommendation is to dilate the sphincter thor- 
oughly under nitrous oxide gas, for the purpose of overcom- 
ing sphincterismus or sphincteralgia, which they think has 
been the cause of many of the complications that follow the 
use of this method. This is to be done four or five days 
prior to beginning the injections of the hemorrhoids. They 
recommend the use of a small conical speculum (Fig. 81), 
with the distal end cut off at an angle of forty-five degrees, 



HEMORRHOIDS 253 

the edge of which is protected by a small wire bead running 
completely around it; the angle at which the distal end is cut 
allows the hemorrhoids on that side of the instrument to pro- 
trude into the mouth of the speculum, and by rotating the 
speculum the hemorrhoids in every segment can thus be made 
to protrude into its mouth. Each hemorrhoid is to be injected 
separately, and at intervals of from five to seven days, the 
surface of the hemorrhoid having been first carefully swabbed 
off with some mild antiseptic solution, such as creolin I per 
cent. ; the injection should be made directly into the most 
prominent portion of the pile, very slowly, drop by drop, 
watching carefully the change of color. When the whole or a 
larger part of the visible surface of the pile has assumed a 
whitish color, the hypodermic needle should be withdrawn 
carefully, and as the point of the needle reaches the point of 
exit an additional drop of the fluid is forced out of the syringe 
to seal the opening. The speculum is then withdrawn, before 
removing the needle, allowing the rectal walls to collapse, 
which prevents the hemorrhoid from protruding after it has 
been injected. They recommend for the injection a solution 
of equal parts of phenol bobceuf and distilled water, freshly 
prepared and filtered, the fluid to be discarded if it becomes 
opaque. Ordinary cases require an injection from 7 m. to 
15 m. After the injection, they recommend the introduction 
of a suppository containing J / 2 gr. cocain to prevent the slight 
discomfort which may be felt for the first hour, and also a 
suppository containing 3 m. of ichthyol, and the latter sup- 
positories are to be used during the entire course of treatment, 
one at bed-time and one after the bowels are moved. The 
bowels are to be moved daily. 

Character of Hemorrhoids to be Injected. — Quoting 
Martin further : " It might seem unnecessary to describe the 
forms of hemorrhoids suited to the injection treatment, but I 
have been asked so frequently if I inject external hemorrhoids 
that I wish my views to be thoroughly understood. Under 
no circumstances do I inject external hemorrhoids, nor any 



254 DISEASES OF ANUS, RECTUM, AND SIGMOID 



structures covered by true skin. Internal hemorrhoids, and 
cases in which there is a prolapse of the mucous membrane 
only, are treated by this method. External hemorrhoids and 
hypertrophied anal folds are so readily and painlessly removed 
under local anaesthesia, while the injection of these structures 
causes so much irritation, besides the clanger of infection, that 
I do not believe we are justified in employing the latter treat- 
ment in these cases. When an internal hemorrhoid, from long- 
continued irritation and inflammation, has become excessively 
hypertrophied and fibrous, I feel that the wisest course to 
pursue would be to anaesthetize the tumor and remove it with 





Fig. 82. — A diagrammatic sketch to show where the injections have been made. 

a clamp and cautery or by ligature. Many piles of this variety 
can be absorbed by the injection, but the process is long and 
tedious and may result in failure." 

" It is rather important to keep a systematic record of the 
hemorrhoids treated, both for convenience during the course 
of visits, and also in case of a return of the condition, to know 
if the recurrence has been in situ, or in some other segment 
of the bowel. For convenience the mucosa is divided into 
eight segments, as shown in the sketch above, and the injec- 
tions may be designated by the initials A, P, R, L, or Ar, Al, 
Pr, or PL. Also a note may be made of the amount of fluid 
employed. In the sketch the crosses (X) show where the 
injections have been made" (Fig. 82). (From C. Martin's 
Paper, page 13.) 



HEMORRHOIDS 255 

" The only complication I have ever encountered has been 
the production of a small slough, associated with a sense of 
discomfort and fulness in the rectum. No noticeable pain 
follows, unless the sphincter has not been thoroughly divulsed, 
and the slough heals readily after a couple of applications of 
the stick silver nitrate." 

" The injections should be continued until all the hemor- 
rhoids have been absorbed and the rectal mucosa does not 
prolapse into the speculum to any extent when the patient 
coughs hard. The fact that the patient is comfortable, and 
that the piles do not come down at stool, does not indicate a 
cure, for if any hemorrhoidal tissue remain the percentage of 
recurrences will be materially increased. Under careful treat- 
ment I would estimate the recurrences at about 15 per cent., 
these usually occurring after an interval of from three to five 
years. If the recurrence does not take place and the primary 
divulsion has been thoroughly performed, a second divulsion 
is rarely necessary, and the patient can usually be permanently 
relieved by a few additional injections." 

" The causes of sloughing following the injection are prac- 
tically fourfold: 1. Spasm of sphincters interfering with the 
circulation; 2. Superficial injections causing destruction of 
the mucous membrane ; 3. Strong solutions causing a blocking 
of the circulation with destruction of tissue; 4. Toe large 
injections causing excessive irritation with pressure necrosis. 

" There is no doubt that the sloughs usually formed are 
sterile, but after separation begins it is perfectly possible for 
the granulation surface below to become infected from the 
faeces, or rectal discharges. For this reason sloughs in the 
rectum, however produced, are to be avoided, and the fewer 
formed the less the likelihood of serious consequences fol- 
lowing treatment. In my own practice, I doubt if sloughs 
ever occur in over 3 per cent, of cases, and when they do 
occur they are watched carefully until there is no danger of 
infection. " 



256 DISEASES OF ANUS, RECTUM, AND SIGMOID 

" In connection with the injection treatment, the operation 
of divulsion of the sphincter seems to deserve some special 
mention. There are two methods to consider, one a gradual 
dilation with sounds and dilators, and the other a rapid divul- 
sion under anaesthesia, employing either the fingers or the 
mechanical dilators. Gradual dilation in my hands gave very 
imperfect results, and the effect of the process was not lasting. 
Often the procedure, instead of relaxing the muscles, seemed 
to add to their irritability, by reason of the exercise given 
them, so that I have discontinued the practise. Rapid or 
forcible dilation or divulsion of the sphincters presents two 
distinct types of technic for study. In the first, the operation 
is performed in a few seconds under the influence of the anaes- 
thetic, in which the reflex action of the sphincters is preserved, 
or even accentuated, as with nitrous oxid or ethyl chlorid; in 
the second, the procedure involves careful stretching and mas- 
sage of the muscles while relaxed from full anaesthesia, pro- 
duced by means of ether or chloroform. This second variety 
is that usually performed by the general surgeon, and has been 
fully described in text-books treating of this subject." 

" The administration of nitrous oxid is admirably adapted 
to the short operation of rapid divulsion. Under its influence, 
the sphincteric reflexes are retained, and even accentuated, this 
contraction offering a good index as to the amount of force 
to be used in the operation. After the patient is anaesthetized, 
the muscle is stretched manually, until the fibres just begin 
to give away under the fingers. It is unsafe to continue beyond 
this point, as it is undesirable to lacerate the muscle fibres. 
As soon as the patient recovers consciousness, a hot compress 
should be applied firmly to the anus for about five minutes. 
The patient may then be allowed to go home, being instructed 
to use the compresses every three hours, if he has much sore- 
ness from the traumatism. He may return to work the next 
day. At the end of four or five days, after the muscle has 
recovered from the bruising, the treatment by injection may 
be commenced. Hemorrhoids which were before inflamed, 



HEMORRHOIDS 257 

ulcerated, or bleeding have from the improvement in the vas- 
cular condition of the muscle been converted into simple inter- 
nal hemorrhoids. Bleeding from hemorrhoids rarely persists 
after divulsion, a feature greatly appreciated by the patient." 

" The length of time necessary to complete a cure varies 
with the number of hemorrhoids present, and the length of 
time they have existed. Ordinary cases require from three 
to twelve treatments, and although some require more, yet the 
result is always positive if the treatment is followed out con- 
scientiously. I have treated now about three hundred and 
fifty patients by this method, with nothing but good results, 
and I see no reason, from what I have seen of the results 
obtained by my father in over four thousand cases, to expect 
anything but satisfaction from the employment of this 
method." 

My own experience with the injection of hemorrhoids has 
not been at all satisfactory, although I have tried most of 
the improved methods, except that of Dr. Martin, and such 
has been the experience of many others. 

Electrolysis. — This method has been recommended by 
Dr. Ball and quite a number of others. After a careful and 
thorough trial of this method some years ago, I discarded it ; 
having found it unsatisfactory and inefficient. It would con- 
trol the bleeding, but not destroy the tumors sufficiently to 
prevent a recurrence in a short time. The first effect of the 
treatment on the hemorrhoidal tumor would be to produce 
coagulation of the blood in the tumor, which would either 
break down and form a slough or subsequently become organ- 
ized and cause some shrinking of the tumor. 

Treatment of Capillary Hemorrhoids. — While these 
tumors bleed very readily and freely from their surface, yet 
when they are cut off there is very little danger from exces- 
sive loss of blood from this cause. It is better, however, to 
use some means for controlling the bleeding when they are 
removed, which can best be done by the use of the angiotribe 
(Fig. 83) devised (by Downs & Co.) which controls the bleed- 
17 



258 DISEASES OF ANUS, RECTUM, AND SIGMOID 

ing and at the same time destroys the tumor ; or a ligature may 
be thrown around it and tied, and the tumor cut off. Either of 
these means may be used without a local anaesthetic. The only 
objection to the angiotribe is the difficulty of protecting the 
anal margin from the painful effect of the heat, even though 
a protecting shield is used (Fig. 84). 

Treatment of Varicose and Thrombotic Hemor- 
rhoids. — Preparation of the Patient. — Let the bowels be 
thoroughly emptied, ten or twelve hours prior to the opera- 




Protecting shield to be used with the angiotribe. 



tion and about two hours beforehand well washed out with 
several enemas of tepid water; the toilet for the operation 
should be made immediately before operation, and consists of 
a thorough washing out of the rectum with soap and water, 
shaving and washing the external parts, and finally irrigating 
them with 1-1000 solution of bichloride of mercury; the 
rectum then should be packed with sterile gauze to prevent 
fecal matter from coming down from above and soiling the 
field of operation. Probably the best position is the exag- 
gerated lithotomy one, with the hips well elevated and the 
legs held over the abdomen by the shoulder-straps. 



HEMORRHOIDS 259 

The Anccsthctic. — It is now generally conceded that almost 
any case of hemorrhoids can be operated upon satisfactorily 
by local anaesthesia, the technic of which has been already 
given. There may, however, be reasons or conditions why 
the operator should prefer a general anaesthetic. Personally, 
I prefer it in all cases except single hemorrhoids, or where 
there is some special objection. 

Dilate the sphincter thoroughly before beginning to 
operate, either by the ringers or with the thumbs in the rectum 
and the fingers external to the tuberosities, using the same 
for a fulcrum ; Kelly's conical dilator is much better. With 
care in the use of this instrument, the muscle can be thor- 
oughly dilated without much risk of tearing it, and altogether 
it is very satisfactory. 

The Ligature Operation. — This has been in use for many 
years, though more generally in England than in our country, 
Allingham having done much to popularize it there. In 
America J. McDowell Mathews, of Louisville, Kentucky, 
has been a very ardent advocate of it. 

It consists in first pulling the hemorrhoids well down with 
catch, or T forceps, then with a pair of scissors the incision 
is begun at the base of the tumor on the skin surface, and is 
continued up under the tumor until it reaches its upper limit, 
when the artery is felt for in the pedicle, and is held until the 
pedicle is trimmed down close to it. A strong silk ligature is 
then thrown around the pedicle and tied tightly. I prefer 
transfixing the pedicle with a double ligature and tying it on 
each side (Fig. 85). The hemorrhoid is then excised close 
to the ligature, each hemorrhoid being removed in a similar 
manner. If any skin-tags exist they are cut off flush with the 
surface of the skin and the bleeding controlled by compression. 
The wound is then dressed with sterile gauze, wrung out in 
a solution of bichloride of mercury 1 to 1000. 

The results are most satisfactory and the death rate 
extremely low. 



260 DISEASES OF ANUS, RECTUM, AND SIGMOID 

After-Treatment. — To avoid repetition, the after-treatment 
following the ligature operation is similar to that following 
other operations for excising hemorrhoids. Therefore what 
I state here will answer for them all. Pain should be con- 
trolled at first by hypodermics of morphia, subsequently by 
codein one-half of a grain, and acetanilid gr. 3, guarded by 
caffeine citrate gr. 1. The morphia will control the bowels 
until the fourth day, when they should be moved by com- 
pound licorice powder, or castor oil, followed by a warm 
enema when the first impulse for an evacuation begins. 




Fig. 85. — Transfixing a hemorrhoid with a needle threaded with a double ligature. 

The diet to be of a laxative character, such as fruits and 
vegetables, and in order to still further insure a soft stool 
give three half-ounce doses of olive oil on the third day. 

Dressings. — Remember, in the after-treatment of rectal 
wounds of all kinds there is a different condition to meet than 
elsewhere on the surface of the body, and worse than at other 
orifices, on account of the infected character of the discharges, 
even though they only consist of mucus. These are con- 
tinuously and unavoidably coming down over the wound and 



HEMORRHOIDS 261 

infecting it. Control the growth of the organisms that are 
on the wound by frequent irrigations with antiseptic solu- 
tions and frequent changes of dressings. On the third day 
the patient may be allowed to be about his room, and on the 
seventh to leave the hospital. 

Method by Clamp and Cautery. — This method, originating 
with Cusack of Dublin in 1864, was introduced into London 
by Mr. Henry Lee, and brought prominently before the med- 
ical profession of England by Henry Smith in 1864. It still 
holds its own and has many advocates in spite of the fact that 
it seems to be an antiquated method in the light of the advance 
in antiseptic surgery. While it was unquestionably a great 
boon to rectal surgery at the time, and for many years follow- 
ing, when methods for controlling hemorrhage were very 
meagre and we had no' knowledge of antiseptic surgery, I 
fail to see now any good reason for continuing it under present 
conditions, when tumors in every other portion of the body 
and under nearly every condition are dealt with by modern 
methods, namely, excision with immediate suture. There is 
no question about the superiority of the latter over the clamp 
and cautery for neatness and accuracy in removing just what 
is necessary, for the perfect control it gives over hemorrhage, 
and in ultimate results; and these advantages are still further 
emphasized by the fact that they can be done under local 
anaesthesia. 

The following is the technic for the clamp-and-cautery 
operation : The patient having been previously prepared and 
anaesthetized, is placed in the lithotomy position, with the 
limbs well flexed and held in position by shoulder-straps, or 
a Clover crutch. The sphincter is thoroughly dilated and the 
hemorrhoids exposed by everting the anus. 

Each tumor is caught with Tuttle's hemorrhoidal for- 
ceps (Fig. 86), in a line parallel with the long axis of the 
bowel, and drawn well down. If only an internal hemorrhoid, 
it is clamped at its base, parallel with the long axis of the 



262 DISEASES OF ANUS, RECTUM, AND SIGMOID 

bowel, the screw of the clamp being tightened sufficiently to 
hold the stump firmly without danger of slipping. If the 
hemorrhoid is not too thick it should be excised with the 
Paquelin cautery-knife, heated to a dull red heat. If very 
fleshy, it may be excised with scissors, a quarter of an inch 
above the surface of the clamp. The stump should then be 
thoroughly cauterized with the cautery-point at a dull red heat. 
In a case of mixed hemorrhoids, excise the base of the 
external portion of the hemorrhoid with scissors to a point 
above the mucocutaneous border, after which apply the clamp 
to the internal portion of the hemorrhoid, screw it down, and 
remove the portion of the hemorrhoid above the clamp, either 




•Tuttle's hemorrhoidal forceps. (Tuttle.) 



by scissors and then cauterize the stump, or by the cautery 
knife as previously described. Remove each hemorrhoid in 
a similar manner, taking care to leave a strip of skin and 
mucous membrane intact between the two, also that no portion 
of the skin surface of any hemorrhoids be cauterized. Excise 
skin-tags or redundant portions of skin that remain with 
scissors at the level of the skin surface. 

Subsequent Treatment. — James P. Tuttle suggests cau- 
terized stumps being freely dusted with bicarbonate of soda 
to allay the burning occasioned by the cautery. The stumps 
are now returned, if they have not already done so spontane- 
ously, and a compress applied which is held in position by a 
tightly-fitting T bandage. A hypodermic of morphia gr. J4 
is given, which may be repeated every two or three hours if 
the patient is in pain. 



HEMORRHOIDS 263 

If it is necessary to sponge off the stumps of the hemor- 
rhoids, it should be done by direct pressure with a sponge, 
and not wiped from side to side, for fear of separating the 
cauterized surfaces. 

I do not recommend the introduction of tubes or packing, 
after operation, as they increase the pain, especially when 
being removed. 

Have the bowels moved on the third day with some gentle 
laxative, and every day thereafter by warm enemas, and wash 
off the wound with a w T eak solution of bichloride of mercury 
twice daily, dusting with antiseptic powder N. F. 

The patient may be allowed to get out of bed on the third 
day after the bowels have been moved, and generally allowed 
to leave the hospital on the seventh day, but the wound should 




Fig. 87. — Linthicum's hemorrhoidal clamp. 

be looked after every alternate day, and treated by stimulating 
applications until it is entirely healed, which requires from two 
to four weeks. The finger should be introduced into the bowel 
on the seventh day, to ascertain if there is any constriction, 
and this should be repeated every third or fourth day while 
the patient is under observation. 

Clamps. — Of the clamps now in use for this operation I 
would recommend those devised by G. Milton Linthicum, of 
Baltimore, Maryland {Philadelphia Med. Journal, June 22, 
1901. Fig. 87), also that devised by Dwight H. Murray, of 
Syracuse, New York (Philadelphia Med. Journal, Sept. 28, 
1908. Fig. 88). These clamps, almost identical in construc- 
tion, were devised and used by their originators some time 
before publication, and each without knowing the other had 



264 DISEASES OF ANUS, RECTUM, AND SIGMOID 

constructed a similar instrument. The blades of these clamps 
maintain a parallel position throughout the limit of their move- 
ments; the hold on the tissues is firm, the thumb-screw easily 
adjusted even by the thumb of the hand holding the blade. 
The handles are sufficiently far apart, even when closed, for 
a firm hold to be maintained, and the instrument is so con- 
structed that it may be disjointed for cleaning and sterilizing. 

The thermocautery is decidedly to be preferred to the 
electric one, because the amount of heat in the former is so 
much more easily regulated, nor is it so intense. 

But as a substitute for the clamp and cautery I would 
recommend the angiotribe, it being far safer and just as 
effectual. With the usual general directions in using the 




Fig. 88. — Murray's hemorrhoidal clamp. 

former, namely, that it should only be used for removing 
internal hemorrhoids, the angiotribe is to be applied with 
the long axis of the rectum, and when there are mixed hemor- 
rhoids, the mucocutaneous base should first be cut through 
with scissors, and the angiotribe applied to the internal 
portions. 

J. Rawson Pennington, of Chicago, Illinois, is very partial 
to what he terms " A simple operation for hemorrhoids " — 
enucleation. 

" The patient is placed in the lithotomy position and the 
limbs held over the abdomen by means of the Clover crutch. 
The usual toilet for the preparation of the patient, as before 
given, having been completed, each anal quadrant is grasped 
at the mucocutaneous junction with a pair of T forceps. These 



HEMORRHOIDS 265 

are held by an assistant. By means of these instruments the 
anus is everted and the internal tumors are exposed. Now 
seizing with the full hand the forceps attached to the posterior 
quadrant, the hemorrhoid is fully everted, and with a pair of 
scissors curved on the flat side the redundant tissue only is 
cut off, usually about one-third or one-half of the uppermost 
part of the hemorrhoidal node. This permits most of the 
blood in the tumor to escape. All of the angiomatous tissue is 
carefully removed, when the remaining wall collapses. This 
leaves a very small area, if any, of denuded surface. Each 
quadrant in regular order is treated in a similar manner. A 
stream of hot sterilized water flows over the field continually 
during the operation. Spurting vessels, if any, are caught 
with a pair of forceps and thoroughly twisted. Should this 
fail to control the hemorrhage I would throw a ligature 
around the vessel and ligate it. So far I have not found this 
necessary. The T forceps are then removed and all external 
tumors and tags of skin cut off with a pair of straight scissors, 
care being taken not to make an incision in the mucocutaneous 
junction, when it can be avoided, as this is the most sensitive 
point around the anus. The same precaution should also be 
observed when removing the internal tumors. The field is 
then dusted with nosophene powder and a rubber-covered 
hollow tampon introduced through a bivalve speculum. Over 
this is placed gauze, and a T bandage. Care should be taken 
that the T bandage is made quite taut. The patient is then 
placed in bed. 

" By operating in this manner there are no tender and 
obstructive stumps to slough, nor nerves caught and squeezed 
(which produces most excruciating pain), as there are when 
the ligature method is used; nor are the nerves and tissues 
burned to a crisp, which is also painful, as when the clamp 
and cautery is employed. In lieu of this, a fibrinous exudate 
is deposited over the operated field, which exudate is neither 
destroyed nor disturbed upon the removal of the dressings. 



266 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Moreover, the danger of stricture is obviated, as the normal 
calibre of the bowel is left practically covered with mucous 
membrane. Neither is the anal orifice contracted, as it neces- 
sarily is after either of the above operations. 

" At the end of forty-eight hours the patient is given a 
cathartic and the tampon removed. Removing it is easy and 
painless. The movement of the bowels is also painless, and 
there is, as a rule, little or no bleeding." 

" From this time on until convalescence is well established 
the parts should be washed or irrigated twice a day with an 
antiseptic solution, and dusted with some powder, as iodo- 
form, boracic acid, or nosophene. I have used the latter drug 
almost exclusively for the past eighteen months and prefer it 
to either of the others. After the bowels have been moved 
the patient is instructed to keep them soft for two or three 
weeks." 

Excision with Immediate Suture. — This method, in some 
one of the many forms devised within the last few years, 
appeals strongly to the average surgeon of the present day 
as being most rational and in keeping with the methods used in 
other parts of the body for removing tumors. 

Whitehead's Method. — Mr. Walter Whitehead, of Man- 
chester, England, was probably the first to pursue this method 
(1882), after an unsatisfactory experience with the ligature, 
clamp and cautery. 

After the usual toilet, as before described, and with the 
patient under the influence of a general anaesthetic, also the 
sphincter having been thoroughly dilated, so that the hemor- 
rhoids and any redundant mucous membrane may project 
from the anal orifice without any difficulty, the mucous mem- 
brane is divided at its juncture with the skin around the entire 
circumference of the anal margin, every irregularity of the 
skin being carefully followed. 

The external sphincter together with the lower portion of 
the internal sphincter are then exposed by rapid dissection, 



HEMORRHOIDS 267 

with the blunt end of curved scissors, and the mucous mem- 
brane and the attached hemorrhoids, separated from the sub- 
mucous layer, are pulled down and brought below the margin 
of the skin. 

The mucous membrane above the hemorrhoids is now 
divided transversely in successive stages, and the free margin 
of the severed membrane is attached, as soon as divided, to 
the free margin of the skin below, by the necessary number of 
sutures, to keep the cut surfaces in apposition. This excision 
of the pile-bearing mucous membrane is continued around the 
entire anal margin and bleeding vessels throughout the opera- 
tion are twisted when divided. 

Mr. Whitehead is very careful that no skin be sacrificed, 
however redundant, and says : " The little tags of super- 
fluous skin soon contract and eventually cause no further 
inconvenience." He states that there is practically no hemor- 
rhage during the dissection, but such has not been my experi- 
ence, nor that of any surgeon whom I have seen operate by 
this method. In the three hundred cases that Mr. Whitehead 
reported, he did not have a single case of secondary hemor- 
rhage. Before closing the wound, he dusts the raw surfaces 
with iodoform, for the purpose of controlling the oozing. He 
uses carbolized silk sutures, and never takes out the stitches. 
An ice-bag is kept on the rectum for the first few clays, and 
the bowels are moved on the fourth day. The patient sits up 
on the same day, and is allowed to resume his work in two 
weeks. The amount of pain varies with the sensibility of 
the patient, but as a rule it is considerable, and requires the 
use of morphia. He states that the time required for the 
operation is short. 

Mr. Whitehead's experience with this method has not 
been borne out by other operators ; their objections being the 
amount of blood lost ; the length of time required ; the uncer- 
tainty of primary union ; the danger of stricture, and the 
probable incontinence that is likely to follow on account of 



268 DISEASES OF ANUS, RECTUM, AND SIGMOID 

the necessary removal of certain anatomic structures, espe- 
cially the tactile or sensitive margin of the anus, with its 
papilla. 

While such a result may follow operations with the liga- 
ture, clamp, and cautery, it is not nearly so likely as in White- 
head's operation, and the danger of subsequent contraction at 
the anal orifice is much greater in the latter. 

I have devised a modification of Whitehead's operation, 
which does away with most of the objections urged against 
the latter, for, instead of excising all of the pile-bearing mem- 
brane as suggested in Whitehead's operation, many surgeons 
prefer to excise the individual pile-tumors and close the wound 
with cat-gut sutures. Gallant (Mathczvs Medical Quarterly, 
October, 1894), states that Outerbridge had followed this plan 
since 1888 with great success. This suggestion appealed to 
me very strongly, especially as I was casting about for some 
more satisfactory method for operating than that recommended 
by Dr. Whitehead, or the clamp and cautery, neither of which 
had proved satisfactory, after a most careful and prolonged 
use of each. 

After having followed Outerbridge' s suggestion for some 
time, I found it necessary to devise some means to prevent 
the opposite walls of the adjacent hemorrhoids from being 
included in the sutures of the wound that was being closed; 
in other words, some means of keeping the hemorrhoid that 
is being treated distinctly separate from its neighbors. This 
was accomplished by devising the pile-forceps (Fig. 89). 
These are seen to have conical-shaped blades, over which, the 
suture will slip very readily ; they have serrated edges and are 
purposely not made sufficiently strong to bruise the tissues 
which they clamp. 

Similar suggestions seem to have occurred to others, about 
the same time, independent of each other. 

In order to authenticate distinction of priority, I give 
the dates on which each method was first published. 



HEMORRHOIDS 269 

Earle (Mathews Medical Quarterly, January, 1896), and 
Parkhill {International Journal of Surgery, May, 1900). 
Both of these have devised instruments for holding individual 
hemorrhoids while being excised and sutured, also to facilitate 
the Whitehead method, and to overcome its objections. 

All of these methods are very similar, but as Earle's pre- 
ceded all others, I give only that. 

Earle's Method. — With the patient prepared for operation 
in the usual manner, the sphincter is stretched and the parts 
thoroughly cleansed. When the hemorrhoidal tumor is single, 
whether internal or mixed, it should be caught with the ordi- 




Fig. 89. — Earle's straight hemorrhoidal forceps. 

nary catch or T forceps and dragged well down and out of 
the anal canal. It is then clamped at its base, in the line of 
the long axis of the rectum, by the Earle hemorrhoidal clamp; 
a suture of cat-gut is placed at the uppermost border of the 
hemorrhoid, directly beneath the toe of the clamp. After the 
suture is tied firmly the portion of the pile above the clamp is 
cut off, a small portion at a time, followed by a running suture 
that is passed beneath and then carried over the top of the 
clamp; these two steps in the operation are continued alter- 
nately, until the whole of the pile within the grasp of the 
clamp has been excised, and its stump sutured. The suture is 
not drawn tightly around the clamp, so the latter may be 
loosened and slipped out readily; this is done, after which 



270 DISEASES OF ANUS, RECTUM, AND SIGMOID 

the suture is drawn tight, thus completely closing the wound; 
the suture is tied at its distal end with a running knot. Each 
hemorrhoid is treated similarly in turn, until all are removed; 
care being taken to leave a strip of skin and mucous membrane 
between each of those that are removed. 

The operation can be done very satisfactorily under local 
anaesthesia, using ]/ 2 oi i per cent, solution of cocain for the 
first two injections, one at each commissure, and J4 of I 
per cent, solution for injecting each of the hemorrhoids, when 
each is ready to be excised. 

The whole circumference of the anal margin is perhaps 
surrounded by mixed hemorrhoids which coalesce and cannot 




Fig. 90. — Hebb's modification of Earle's hemorrhoidal forceps. 

be separated into individual tumors (just such a condition 
as would usually be dealt with by Whitehead's operation), 
and here a modification of Whitehead's operation, with either 
the straight or curved hemorrhoidal clamp is done; the latter 
is a modification of the writer's straight clamp by Arthur 
Hebb (Fig. 90). 

The principle of this operation is the same as that given 
for the removal of individual hemorrhoids, except that the 
clamp is applied horizontally to the long axis of the bowel 
and the manner of proceeding is correspondingly different. 

The hemorrhoids are caught at their uppermost limit by 
T forceps and all are drawn well down and outside the bowel. 
A longitudinal incision is made with scissors at the posterior 



HEMORRHOIDS 



271 



commissure, sufficiently deep to allow the hemorrhoids to be 
cut off horizontally below the border of the external sphincter. 
A suture is now passed through the mucous membrane at the 
upper angle of this wound, then over the lower border of the 
sphincter, and out through the skin; the suture is tied, thus 
drawing together the mucous membrane and skin at the upper 




Fig. 91. — Earle's modification of Whiteh 



; operation — first step. 



angle of the incision (Fig. 91). The curved hemorrhoidal 
clamp of Hebb is made to clasp the base of the protruding 
hemorrhoids, external to the sphincter and to the right of 
the longitudinal incision ; the same suture is passed from 
within out, beneath the forceps (Fig. 92) ; the hemorrhoidal 
mass is then partly excised with Hebb's curved scissors (Fig. 



272 DISEASES OF ANUS, RECTUM, AND SIGMOID 

93), beginning at the heel of the forceps. The hemorrhoidal 
mass is excised in sections. After each excision the suture 
is carried over the forceps to be introduced at their base on 













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1 








' ; ''"^ ,< ^ : 


lL 


\ 


W£S&£**mmm* 






•V" 


-p? 




"^^^ 




S* 












- 









Fig. 92. — Earle's modification of Whitehead's operation — second step. 

the mucous surface, to be passed out again beneath the clamp. 
This alternate cutting and sewing is continued until all the 
hemorrhoids within the grasp of the clamp have been removed. 
The clamp is loosened and removed, and the suture drawn 



HEMORRHOIDS 273 

taut by the aid of a hook at the end of the clamp, which 
approximates the mucous and skin surfaces over the sphinc- 
ter, closes tightly the wound, and stops all hemorrhage. By 
sewing from within out the skin margin is turned in and thus 
ectropion of the mucous surface is prevented. The succeeding 
portions of the protruding hemorrhoids are successively 
clamped, excised and sutured in sections until they have all 
been removed and the suture is continuous from the beginning 
to the close, when its two ends are tied at the starting point 
(Fig. 94). 

It will be seen that when the hemorrhoids are dragged 
down by T forceps, both the skin and mucous membrane 
slip easily down over and below the sphincter muscle, so that 




Fig. 93. — Hebb's curved scissors. 



with ordinary care there is only slight risk of excising any 
portion of the sphincter muscle, and that practically the same 
thing has been accomplished by this method as by the White- 
head operation, with much less risk of infection, far less 
loss of blood, and in much less time (from twenty to twenty- 
five minutes being the usual time taken by the author for 
the operation). 

The packing is now removed from the rectum, the wound 
cleansed with sterile water and dressed with dry sterile gauze. 
I have several times done the complete operation very satis- 
factorily under local anaesthesia, using the K and ^ of 1 
per cent, solutions. 

Complications. — It sometimes happens that the proximal 
end of an incised artery may be exposed between the stitches 
18 



274 DISEASES OF ANUS, RECTUM, AND SIGMOID 

of the running suture. This can readily be observed before 
the close of the operation, when it can be controlled by running 
a mattress suture around it. 

While primary union is much more certain to follow this 
modification than the Whitehead operation, because the cut 
surfaces are closed immediately, without being exposed to 
infection, yet it sometimes happens that the wound does become 
infected and consequently heals by granulation; it is when 



r 




Fig. 94. — Earle's modification of Whitehead's operation — complete. 

such an infection occurs that we are likely to have constric- 
tion of the anal orifice, and I am firmly convinced that any 
method of excising hemorrhoids which removes the skin and 
mucous membrane from the entire circumference of the anal 
margin is almost certain to be followed by constriction of the 
same if the operator fails to get union by first intention. 

I am equally certain that in a certain class of cases there 
is a predisposition to the formation of fibrous tissue following 
operative procedures, which, so far as I know, cannot be 



HEMORRHOIDS 275 

ascertained beforehand; therefore, it is best to make it a 
rule to dilate the anal orifice from eight to nine days after 
whatever operative procedure has been used for the removal 
of hemorrhoids ; this to be repeated as often as the operator 
thinks best from the amount of constriction existing. 

As it is conceded that such constrictions are more likely 
to follow operations where the skin and mucous membrane 
have been removed from the entire circumference, I recom- 
mend that whenever possible there should be strips of skin 
and mucous membrane left between the excised hemorrhoids. 

For the past six months the author has pursued this 
method in every case of mixed hemorrhoids, and finds it most 
satisfactory even in those cases that are specially adapted to 
Whitehead's operation or any of its modifications. The fol- 
lowing is the technic : 

The internal hemorrhoids are removed individually, by 
Earle's straight clamp and suture method, not allowing the 
excised tissue to extend below Hilton's white line (Fig. 
95). Transverse elliptical pieces of skin, subcutaneous. 
tissue, and varicose vessels are then removed from the 
skin margin of the anus, not allowing the incision to extend 
beyond the mucocutaneous line. About three of these are 
removed from each side of the anal margin in aggravated 
cases, fewer in mild cases. If there are many varicose vessels 
under the strips of skin that are left between each elliptical 
incision, they are dissected out with curved scissors and 
dressing forceps. Spurting vessels are clamped and twisted. 
The compression by the dressing will control all oozing. The 
parts are then washed with a solution of 1 to 1000 bichloride 
of mercury, and a compress of sterile- gauze is then applied 
with firm pressure, which is held in place by a T bandage. 
Subsequent dressings and sponging with the solution of 
bichloride of mercury are to be repeated several times daily. 
No attempt should be made to draw the external incision 
together by sutures, and it is remarkable how the edges of the 
wound coapt themselves, as will be seen (Fig. 96). 



276 DISEASES OF ANUS, RECTUM, AND SIGMOID 

When this last method is used, it would be better to irri- 
gate the rectum on the second and third day with tepid water, 
on account of the retention of blood and debris from the 
internal wound. This should be done in the recumbent 
posture, the discharge being received in a bed-pan, in order 
to avoid straining at stool. 

General Complications following Operations for Hemor- 
rhoids. — Probably the most common of these is strangury 




Fig. 95. — Modification cf Earle's operation, 



and dysuria. This is best overcome by permitting the patient 
to stand or sit up in the effort to pass water; if this fails, 
then moist heat in the form of cloths wrung out of hot water, 
with a hot-water bag over them, should be applied to the 
parts. If this fails, then the patient should be catheterized, 
but not until ample time has been given to accomplish the 
desired results. 

Secondary Hemorrhage. — Should secondary hemor- 
rhage follow an operation for hemorrhoids, no time should be 



HEMORRHOIDS 277 

lost in placing the patient under a general anaesthetic and 
ligating the bleeding vessels. We think this is far better than 
to temporize with styptics, or to rely upon controlling the 
hemorrhage by compression, through packing. They are too 
uncertain, and do not justify the risk of excessive loss of 
blood, which may occur before there are external evidences 

of it. 

/S> c r ,Q.. C u rr\. •• . ;,; 







Fig. 96. — Modification of Earle's operation — complete. 

The author has recently encountered a case of secondary 
hemorrhage which was undoubtedly caused by the systemic 
effects of cocain, which had been administered as a local 
anaesthetic for the removal of a mixed hemorrhoid. The 
following is the report of the case : 

Dr. C. W. McE. was operated upon by the author, Sep- 
tember 2, 1909, for the excision of a mixed hemorrhoid, from 



278 DISEASES OF ANUS, RECTUM, AND SIGMOID 

which he had lost considerable blood whenever he went to 
stool. The author injected a solution containing y$ grain of 
muriate of cocain, and immediately afterward proceeded to 
remove the hemorrhoid, first by clamping the internal portion 
of it, cutting it off and suturing it, while the stump was held 
in the clamp; the external portion of the hemorrhoid was cut 
off without suturing it. The wound was then dressed with 
sterile gauze and the patient placed in bed. Immediately after- 
ward he complained of excessive heart action and some dizzi- 
ness. Two hours after the operation the wound began to 
bleed, the blood oozing from the entire raw surface of the 
external portion of the wound to such an extent and in spite 
of firm pressure that it was deemed necessary to place him 
under a general anaesthetic and close the wound with cat-gut 
sutures. A heart sedative was administered after he came 
from under the general anaesthetic, to 1 quiet the excessive 
heart action. While the patient was under the anaesthetic the 
author removed several other internal hemorrhoids, clamping 
and suturing them. There was no subsequent bleeding, and 
he made a most satisfactory recovery. 

The patient subsequently stated that on two* previous occa- 
sions he had had an excessive hemorrhage following the use 
of cocain, one from the extraction of a tooth, and the other 
from incising a boil, although he has shown no tendency to 
bleed from ordinary cuts or abrasions. 

Erysipelas, Tetanus, and Infection. — These are all 
liable to follow operations on the rectum, or its surroundings. 
They can only be avoided by following a rigid technic during 
the operation and during the period of convalescence. 

Ulceration and Fissure. — These may also follow any 
of the operative procedures for hemorrhoids, and are to be 
treated as before recommended under their respective 
headings. 



CHAPTER XI 
PROLAPSE OF THE RECTUM 

Prolapse (from prolabi, to slip down) signifies a falling 
or protrusion of the rectal wall from its normal position, 
whether within or without the anal margin and to all degrees 
of prolapse. I exclude procidentia (from pr odder e, to fall 
down) because the term is practically the same as prolapse 
and so is likely to be confusing. 





'% 



Fig. 97. — Incomplete prolapse. 

Prolapse of the rectum is divided into incomplete, in which 
only the mucous coat of the bowel protrudes, and complete, in 
which all of the coats protrude. 

Incomplete Prolapse. — This is a protrusion from the 
anal margin of the mucous membrane of the rectum (Fig. 97) 
and due to undue stretching of the loose fibrous and elastic 
tissue that connects the mucous membrane to the submucous 
and muscular layer. 

Etiology. — The disease is very frequent in young children 
who have been very much depleted in flesh by exhaustive 

279 



280 DISEASES OF ANUS, RECTUM, AND SIGMOID 

summer diarrhoea, coupled with frequent tenesmus and strain- 
ing at stool. It is also due to polypi, especially when pedun- 
culated and attached just above the anal margin, where they 
are likely to be caught within the grasp of the sphincters 
and drag the mucous membrane down. They may also be 
due to the presence of internal hemorrhoids, which are liable 
to be caught in a similar manner during the act of defecation. 
It occurs in inflammatory conditions associated with oedema 
in the very old ; from whatever interferes with the normal 
supports of the rectum, as dilatation of the sphincter or com- 
plete rupture of the peringeum through the anal orifice; or 
from any cause that separates the mucous from the muscular 
coat, or produces an undue amount of straining. 

Symptoms. — The characteristic symptom of incomplete 
prolapse of the rectum is the undue protrusion of the mucous 
membrane beyond the anal margin. This may be very slight 
at first, and the prolapsed mucous membrane returns volun- 
tarily, very promptly, after the act of defecation. Soon, 
however, the prolapse increases and its return into the rectum 
is correspondingly prolonged. 

It may protrude partially or entirely around the anal 
orifice. It is frequently associated with hemorrhoids and 
neoplasms. 

When the protrusion involves the entire circumference 
of the anal orifice, it is smooth on its surface, unless associated 
with hemorrhoids or neoplasms, and is divided into longi- 
tudinal folds by furrows, which correspond to the columns 
of Morgagni. There is always more or less protrusion of 
the mucous membrane of the rectum associated with extensive 
internal hemorrhoids. The color of the prolapsed mucous 
membrane is at first normal, but the part soon becomes inflamed 
and irritated from exposure and friction, followed sometimes 
by ulceration, slight hemorrhage, and sometimes constriction 
by the sphincter; the latter is not very common, however, in 
the incomplete form of prolapse. 



PROLAPSE OF THE RECTUM 281 

Treatment. — The removal of the exciting cause, if it can 
be ascertained, is always the first step in the treatment, such 
as the excision of hemorrhoids, polypi, and other growths. 

Where prolapse occurs in young children, it can generally 
be relieved without surgical interference by making the child 
have its movements (either on the lap of the mother or else- 
where) in a recumbent position, with its hips elevated, or 
through a very small opening in the toilet seat. The author 
has frequently had these seats made to order, to be placed 
over the ordinary seat of the toilet, with the opening four 
inches long by two inches wide at its greatest width for chil- 
dren, and three by six inches for adults. 

When operative measures are necessary, the recommenda- 
tion of Allingham for cauterizing the prolapsed mucous sur- 
face with fuming nitric acid is a most excellent one, but only 
satisfactory in the treatment of prolapse in children. This 
method, however, evidently did not originate with Allingham, 
as I saw it done in 1868 by Nathan R. Smith, who stated that 
such had been his practise for years, and he was then quite a 
noted surgeon of some seventy years of age. I have fre- 
quently used it since that time and can only recall a single fail- 
ure in cases of incomplete prolapse in young children. 

The technic is as follows : The bowels having been thor- 
oughly emptied, the child is placed under a general anaesthetic ; 
the rectal mucous membrane is stimulated by the introduction 
of the finger, and the bowel made to protrude ; the mucous 
membrane is then wiped free of mucus with a clean towel 
or gauze; the glass stopper of the bottle with nitric acid is 
moistened with the acid by inverting the bottle, care being 
taken that the superfluous acid that accumulates in drops at 
the most dependent portion of the stopper be allowed to run 
back into the mouth of the bottle. The stopper is now intro- 
duced into the protruding portion of the rectal mucous mem- 
brane, great care being taken to prevent the acid from coming 
in contact with the skin margin of the anal opening; the 
stopper is held in contact with the mucous surfaces until they 



282 DISEASES OF ANUS, RECTUM, AND SIGMOID 

become whitened. The mucous surface is now well anointed 
with olive oil, and the protrusion is replaced; a small pad is 
placed over the anus, and the buttocks are strapped together 
by strips of adhesive plaster; the child's legs are also held 
together by bandages, and the patient is confined to bed for 
ten days or two weeks, with the foot of the bed elevated six 
inches. 

Let the bowels be confined by opiates for six or seven days, 
and the rectum emptied at the end of that time, first by injec- 
tions of cotton-seed oil, and then by injections of moderate 
quantities of tepid water. The child is made to have the 
evacuation in the recumbent position, and the evacuations for 
the following two weeks should be made in a like manner. 

The object sought by this method is the agglutination of 
the mucous with the submucous and muscular coats of the 
bowel by inflammatory adhesions. The amount of inflamma- 
tion set up by the acid being slight seems only sufficient to 
correct the mild cases of prolapse seen in children, where the 
tissues have not lost their elasticity. 

The operative measure now generally adopted for the 
treatment of partial prolapse in adults is excision with imme- 
diate suture. The writer is in the habit of treating this form 
of prolapse in the same manner that he does internal hemor- 
rhoids, with his hemorrhoidal clamp and suture, using cat-gut. 
In the absence of the hemorrhoidal clamp an ordinary hys- 
terectomy one will answer. The postoperative treatment of 
these cases will also be exactly the same as for internal hem- 
orrhoids. I do not, however, approve of the ligature method 
as applied to internal hemorrhoids for the treatment of partial 
prolapse. 

Complete Prolapse. — There are three " degrees of this 
form of prolapse : 

First Degree. — That beginning at the anal margin and 
the prolapse involving the anal canal and varying degrees of 
the rectum, according to the extent of the prolapse. 



PROLAPSE OF THE RECTUM 283 

Second Degree. — Where the prolapse begins directly 
above the anal canal and therefore only involves the rectum, 
to a greater or less extent, according to the severity of the 
case, but the prolapsed portion always protrudes external to 
the anal orifice (Fig. 98). 

Third Degree. — Here the prolapse begins still higher up 
in the rectum, or even in the sigmoid flexure and consists in 




A 



Fig. 98.- 



Complete prolapse of the rectum, showing 
(Tuttle.) 



an invagination of the upper part of the rectum or sigmoid 
into the lower, but does not usually protrude through the 
anal orifice, although such is possible (Fig. 99). 

These degrees vary in symptoms and require separate con- 
sideration and treatment. 

First Degree. — This soon follows that of incomplete pro- 
lapse, is brought about by the same general causes, and is 
frequently merely an exaggeration of the same; although it 



284 DISEASES OF ANUS, RECTUM, AND SIGMOID 



sometimes happens that the latter is ushered in abruptly, 
without being preceded by the former. The local causes, 
such as hemorrhoids and polypi, so active in the production of 
partial prolapse, have little to do in causing the complete 
variety, as they only drag upon the mucous coat. Polypi that 
are attached above the anal margin are likely to be active 
factors in its production. 

The characteristic feature of this form is the uninterrupted 
continuation of the mucous with the cutaneous surface, when 
the bowel is prolapsed; there is no sulcus separating the two, 




Fig. 99. — Complete prolapse of the rectum — third degree. 

as in the second degree; in this form also the mucous folds 
are circular, instead of longitudinal, as in the incomplete 
variety. It generally occurs first only when at stool-; sub- 
sequently, when the sphincters and the rectal supports have 
become very much relaxed, it remains down continuously 
unless held in place by artificial means. It is sometimes 
brought about suddenly by lifting heavy weights in the stoop- 
ing position, or by excessive straining. 

'Second. Degree. — This differs from the first only at the 
starting point; in other respects it corresponds in the extent 
of the protrusion and symptoms with the first, as the prolapse 



PROLAPSE OF THE RECTUM 285 

begins at a point above the anal canal and the rectum pro- 
trudes through it; there is a sulcus or space between the pro- 
truding bowel and the anal margin, into which a probe or 
sometimes even the little finger may be introduced to the depth 
at which the prolapse begins. As in the first degree, the second 
never results from hemorrhoids, or tumors, that are attached 
to the lower third of the rectum, nor does the second degree 
ever result from incomplete prolapse. It may be due to what- 
ever produces persistent straining and prolonged effort at stool, 
such as stricture of the rectum, ulceration, or growths attached 
anywhere in the upper two-thirds of the rectum. 

It is generally brought about gradually, but may be pro- 
duced suddenly by violent straining. Sometimes it is exten- 
sive, being only limited by the length of the colon and its 
meson. When protruding more than four inches, it is likely to 
be curved backward, owing to the traction made upon it by the 
mesosigmoid, or mesocolon. There is no possibility of mis- 
taking this form of prolapse for hemorrhoids or neoplasms. 

The continued irritation and excoriation from prolonged 
exposure in chronic forms of prolapse, of either the first or 
second degree, sometimes give rise to a hypertrophic nodular 
condition, resembling very closely an epithelioma of the rec- 
tum, and only to be distinguished from it by a microscopic 
examination of one of the nodules. An extensive prolapse of 
either the first or second degree is likely to be complicated 
by a rectal hernia or archocele, or a descent of Douglas' 
cul-de-sac, in which are coils of the small intestine. In the 
early stages of the prolapse, the coils of the small intestine 
are only found in the anterior portion of the prolapse, but 
where the prolapse is from five to six inches long, then the 
small intestine may nearly surround the prolapsed rectum, a 
point to be remembered before carrying out certain surgical 
suggestions later to be described. This condition can easily 
be recognized by percussion around the circumference of the 
prolapse. 



286 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Third Degree. — This form differs materially from the 
preceding, on account of the prolapse not protruding from the 
anal margin except in rare and very aggravated cases. It is in 
reality an invagination of the upper part of the rectum, or 
lower part of the sigmoid, into the lower part of the rectum. 
As the rectum is capable of great distention in its lower por- 
tion, this invagination does not give rise to complete obstruc- 
tion, as in ordinary invagination of other portions of the bowel, 
nor do the peritoneal coats or the invaginated portion become 
adherent and fixed as they do in the upper portion of the bowel. 
This condition is almost exactly similar to the second degree 
of prolapse, except that as it takes place higher up. in the 
rectum and it rarely protrudes from the anal margin. 

Symptoms. — The symptoms ' are very obscure. Nearly 
always there is a history of constipation which, however, 
may be followed by some diarrhoea; in either case the stool 
does not afford the usual relief and is followed by a sense of 
fulness, some bearing down, and a feeling as though there 
was still more fecal matter to come away ; nor is this sensation 
relieved, but rather aggravated, by laxatives. Enemas are 
very much more effectual both in relieving the bowel of its 
fecal contents and in affording a sensation of relief. This it 
does, probably by lifting the bowel up from below and stimu- 
lating the reverse peristalsis, thus disengaging the invaginated 
portion. There may be a sense of weight and dragging in the 
sacral and lumbar regions, with dull aching pains radiating 
down the lower limbs ; flatulence from the interference with 
the escape of gases, and a mucous colitis. The mucus may 
at first be clear, but subsequently is likely to be tinged with 
blood, due to the irritation from friction of the mucous sur- 
faces rubbing against each other and from the interference 
with the circulation. In rare cases there may be associated 
with these symptoms membranous colitis, with marked 
exhaustion following the stools. 

Etiology. — The causes are exactly similar to those pro- 
ducing the second degree, except that they are likely to be 



PROLAPSE OF THE RECTUM 287 

higher up the rectum, such as growths, constriction of the 
bowel from any cause, especially at the rectosigmoidal junc- 
ture, stricture, an abnormally long mesosigmoid, ulcerations, 
or any cause that produces an undue amount of straining for 
the expulsion of the fecal matter. 

Pathology. — It is perfectly evident to a close observer 
that there is more at fault in the production of prolapse than 
merely a relaxed sphincter, as frequently cases are seen of the 
latter condition without any prolapse. By reference to Chap- 
ter I, it will be seen that the rectum is held in position 
in its lower part by the levator ani and external sphincter 
muscles, perineal fascia and fibrous tissue attaching it to the 
coccyx behind, and to the prostate or vaginal walls in front; 
the middle portion is supported by the loose fibrous tissue 
which passes off from the sacrum along the course of the 
lateral sacral arteries and line the upper surface of the levator 
ani, thus connecting the organ with the osseous frame of the 
pelvis. The superior portion is held in position by the peri- 
toneal folds which connect it with the pelvic walls upon the 
sides, the bladder or uterus in front, and with the sacrum 
behind. Above this the mesosigmoid comprises the chief sup- 
port of the bowel. 

One or more of these supports must be weakened or 
destroyed for the prolapse to occur. Those composed of 
fibrous and elastic tissue lose their efficiency through gradual 
elongation or rupture ; those composed of muscular tissue, 
which are active supports, become inoperative through atrophy, 
injury, or paralysis. 

With these changes there is generally a loss of perirectal 
fat in the spaces that surround the rectum. 

Treatment. — The first requisite is the removal of the 
exciting causes if that can be ascertained, such as hemorrhoids, 
neoplasms, strictures; all ulcerations must be healed, and con- 
stipation overcome. If the prolapse persists, after the re- 
moval of the exciting cause, then the surgeon must proceed 
to restore the rectal supports. 



288 DISEASES OF ANUS, RECTUM, AND SIGMOID 

If the condition has been the result of constitutional debil- 
ity, or an exhausting disease, then this must be overcome by 
appropriate treatment before resorting to any operative meas- 
ures to restore the rectal supports. 

Schmey states that nearly all prolapses in children may be 
radically cured by the administration of phosphorus in increas- 
ing doses. I have never tried this method, but its simplicity 
commends it. Similar results may be expected, in debilitated 
subjects, from the use of strychnia and arsenic; also both the 
galvanic and faradic currents assist the muscular tone. 

While waiting for the beneficial effects from such con- 
stitutional remedies, it is very important to retain the rectum 
in its normal position by the recumbent position of the patient, 
with the foot of the bed well elevated, and by the local appli- 
cation of such means as will stimulate the contraction of the 
sphincter muscles, cold applications being one of the best 
for this purpose. The patient should also be required to have 
his stools in the recumbent position. 

If the rectum is in the habit of prolapsing at other times 
than when at stool, then the buttocks may be strapped in the 
intervals between the stools. 

Constipation can best be overcome, first, by laxative foods, 
such as fruits and vegetables, then by very gentle laxative 
medicines, and lastly, for immediate effect, enemas of a mod- 
erate quantity of cold water. These conservative measures 
may be tried for several weeks before resorting to operative 
procedures. If, however, the prolapse is extensive, is attended 
with spasm of the sphincter, turgescence and sloughing of 
the parts, delay is unjustifiable. Such a condition is not likely 
to occur in children or in old people, and even when it does 
occur in adults of middle age, the sloughing is generally 
limited to the mucous membrane, but sufficient to be followed 
by cicatricial contraction, which is very difficult to heal. 

Reduction. — While ordinarily the prolapsed bowel will 
return spontaneously, or with such assistance as the patient 
will himself give, it sometimes happens that it becomes so 



PROLAPSE OF THE RECTUM 289 

swollen, either from being allowed to remain down too long, 
or from the contraction of an irritable sphincter, that the 
patient is unable to replace it, and seeks the assistance of a 
physician. Generally it will be unnecessary to give a general 
anaesthetic for this purpose, and it should be avoided if pos- 
sible on account of the nausea following. 

By inverting the patient over the end of a table or bed, 
with his head on the floor, and allowing him to remain in 
that position five or ten minutes, it can generally be returned 
without much trouble. If this should fail, then the general 
anaesthetic may be administered and the bowel replaced. 

If when called to a case of prolapse there should be very 
great congestion, cedema, strangury or sloughing, firm pres- 
sure with hot cloths should be made to the prolapsed bowel 
for some time before attempting to reduce it. Cold applica- 
tions are never advisable in these extreme cases, as the blood- 
vessels have become too much distended to respond to its 
action, and it is therefore likely to reduce still further the 
depression in the vitality of the parts, and to produce slough- 
ing. In reducing the prolapsed bowel, let pressure be made 
through the lumen at its end. A piece of gauze must be 
wrapped about the index finger in order to prevent slipping 
and to carry the prolapsed bowel back ahead of the finger; at 
the same time gentle pressure is made upon the body of the 
prolapsed bowel by the knuckles of the same folded hand, 
great care being taken to avoid bruising the bowel. The gauze 
that was wrapped around the finger may be allowed to remain, 
if it is adherent, as it will likely be, until more fresh mucus 
is poured out on the surface. 

After the bowel has been reduced a hypodermic of mor- 
phia, for adults, or a dose of paregoric for children, will 
greatly relieve the straining and quiet the peristalsis. 

If extensive sloughing has taken place, it is dangerous to 
return the prolapsed bowel in that condition, for fear of gen- 
eral sepsis and hemorrhage, and it is better to proceed at once 
to amputate the prolapsed bowel, as described later. 
19 



290 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Operative Treatment. — The method to be used will 
depend upon the extent and the degree of prolapse. If the 
prolapse is of the first degree, and of only moderate extent, 
it will only be necessary to narrow the anal opening in order 
to prevent the prolapse. If it is an aggravated form of the 
first or second degree, where the active and passive supports 
have been stretched or ruptured, they must be restored, or 
others must be devised to take their places. 

As previously stated, the method of Allingham for pro- 
ducing adhesions between the coats of the rectum will not 
answer in these aggravated cases of the first and second degree 
in adults, nor is the suggestion of Van Buren's for -accomplish- 
ing the same result by linear cauterization with the thermo- 
cautery much better. 

In the milder cases of the first and second degree, the 
recommendation made in the aggravated forms of incomplete 
prolapse, of removing the prolapsed mucous membrane, by 
Earle's modification of Whitehead's operation, may answer, 
and should be tried. 

Whitehead's operation is applicable to cases which pro- 
lapse even to the extent of from four to six inches, as the 
mucous membrane can be dissected up from the skin margin, 
while the bowel is prolapsed to that extent ; then cut it off, 
and the upper margin of the cut mucous membrane can then 
be attached to the mucocutaneous margin at the anal orifice, 
the exposed submucous and muscular coats being turned in, 
in order to make the two cut edges of the mucous membrane 
approximate. The technic for this operation, when used for 
this purpose, must be very rigid, for if union by first intention 
fails there will be a very large raw surface exposed by the 
retraction of the mucous membrane. The healing of such a 
large raw surface would not only require considerable time, 
but would almost certainly be followed by a very annoying 
stricture at the anal orifice. I would, therefore, hesitate to 
recommend this method to any except the most skilful sur- 
geons, and even then I think it safer to try one of the other 



PROLAPSE OF THE RECTUM 291 

methods to be described later on; because any operation for 
the relief of the aggravated forms of the first and second 
degree of prolapse limited to the mucous membrane is likely 
to prove ineffectual, and I think those operations involving the 
deeper tissues are preferable. 

Among these is that advised by Lange. He makes an 
incision from the posterior margin of the anus upward along- 
side of the coccyx and deep enough to expose the posterior 
wall of the rectum. The levator ani muscle is dissected back, 
to be replaced before closing the wound; the walls of the 
bowel are then folded in by a line of longitudinal sutures 
introduced through the muscular layer, extending well around 
on each side and then tied, thus narrowing the calibre of the 
bowel and at the same time stiffening its walls. The wound 
is then closed and left to heal by first intention. 

Verneuil {Gas. des hopitaux, May 2, 1892) modified 
Lange's method by gathering the bowel in horizontal folds,' 
after which he sutured it to the sides of the coccyx and 
sacrum by buried sutures, and then closed the external wound. 

As both these operations consist only in suspending the 
lower end of the rectum to the surrounding parts by inflam- 
matory adhesions, and in narrowing its lumen, they do not 
answer for the relief of aggravated cases. George R. Fowler 
{Medical News, New York, February 27, 1897) was the 
first to suggest attaching the rectum to the coccyx by sutures, 
then by inflammatory adhesions; the suggestion of this prin- 
ciple by Fowler led to the introduction of rectopexy by James 
P. Tuttle, the technic of which is: 

Rectopexy or Suspension of the Rectum upon the 
Sacrum. — The patient is prepared by a thorough cleansing 
of the intestinal canal, shaving the peringeum and sacral region, 
and applying an antiseptic dressing the night before. After 
being anaesthetized, he is placed in the semiprone position on 
the left side, with the hips elevated on pillows and the thighs 
well flexed on the abdomen. The prolapse is then dragged 
down to its full extent and held forward by an assistant. A 



292 DISEASES OF ANUS, RECTUM, AND SIGMOID 

curved incision about two inches in length is made midway 
between the coccyx and anus (Fig. ioo). This is carried 
through all the tissues into the retrorectal space. With the 
fingers, or a dull instrument, introduced through this incision, 
the rectum is separated from the coccyx and sacrum pos- 
teriorly, as high up as the attachment of the mesorectum and 
on the sides as far as the attachment of the lateral ligaments. 




. — Rectopexy for procidentia recti — the incision. (Tuttle.) 



Let the latter be sedulously preserved. The anterior surface 
of the bone is then gently curetted to remove all the fatty 
tissue and to freshen it. At this point the assistant reduces 
the prolapse, and with his fingers inside the gut inverts and 
brings it out through the incision (Fig. 101); the operator 
catches the protrusion and drags the gut down as far as it 
will come, usually a little less than the amount prolapsed 
through the anus. The external surface, or muscular wall of 
the gut, thus exposed is then curetted as was the sacrum. 



PROLAPSE OF THE RECTUM 



293 



Silkworm-gut or silver-wire sutures are then passed trans- 
versely through the muscular layer, embracing as much of 
the circumference of the gut as possible; they are placed one- 
half inch apart, and the ends left six to eight inches long. 
After the sutures have been placed, the ends of the upper ones 
are each in turn threaded on a long, curved, Peasley needle 
and carried up through the wound to the highest point of sepa- 




Fig. ioi. — Rectopexy — the gut inverted and brought through the incision; the suture 
passed through its muscular walls. (Tuttle.) 

ration between the rectum and sacrum, where they are made 
to penetrate the tissues, and are brought out through the skin 
on opposite sides of the bone. The other sutures are treated 
in like manner, each being brought out one-half inch lower 
than the preceding one (Fig. 102). The ends are then drawn 
taut, and the prolapse is thus dragged up into the hollow of 
the sacrum where it belongs. A pad of gauze is laid over 
the sacrum and the sutures tied over this to avoid their cutting 



29* DISEASES OF ANUS, RECTUM, AND SIGMOID 

into the skin (Fig. 103). Before tying the sutures the space 
between the rectum and sacrum should be freed from all clots 
and oozing checked. The gut is thus anchored in close appo- 
sition with the sacrum, to which it unites in due time. The 
external wound is closed by buried cat-gut and subcutaneous 
sutures. If the sphincters are much relaxed, or over- 
stretched, a ligature of kangaroo tendon (Fowler) is passed 





Fig. 102. — Rectopexy — the sutures out through the tissues on each side of the sacrum. 
(Tuttle.) 

around the anus at the upper margin of the external sphincter, 
and tied over the index finger introduced through the anus, 
as has been advised by Piatt. This narrows the anal outlet 
and causes contracture of the muscle, thus contributing to the 
cure. The bowels are confined for eight days, when they are 
moved by enemata. The patient is required to remain in bed 
and use the bed-pan for three weeks, after which time he may 
be allowed to go to the toilet. The anchoring sutures are 
left in from ten to fourteen days. 



PROLAPSE OF THE RECTUM 



295 



Up to the publication of his work on " Diseases of the 
Anus, Rectum, and Pelvic Colon," 1905, Tuttle had operated 
in ten cases ; three of them in old people, five in people of 
middle age, and two in children. In two of these the proci- 
dentia had existed for fifteen and eighteen years respectively. 
Seven of them remained cured from one to three years. Three 
have been done less than one year, but so far there has been no 
recurrence. 




Fig. 103. — Rectopexy — the operation completed. (Tuttle.) 



I myself have performed this operation very satisfactorily 
and successfully on two cases of prolapse of the first and second 
degrees. 

The operation is applicable to cases of the first and second 
degrees of prolapse only where the protrusion does not extend 
more than five or six inches. Where more extensive than this, 
it would be well to try the suggestion to be recommended later 
for the treatment of prolapse of the third degree, viz., sig- 



296 DISEASES OF ANUS, RECTUM, AND SIGMOID 

moidopexy, as doubtless many of these cases are either due to, 
or are very much aggravated by, an abnormally long meso- 
sigmoid. In aggravated cases of the first degree, in addition 
to the suggestion to prevent the prolapse by sigmoidopexy, 
it has sometimes been suggested in the same case to narrow 
the anal outlet by the Dieffenbach-Roberts operation, which 
consists in the removal of a section of the rectum at its pos- 
terior commissure, extending about two inches up. The entire 
thickness of the intestine with the sphincter muscles is re- 
moved, and the edges of the wound carefully approximated 
and kept together by cat-gut sutures. This narrows very 
greatly the calibre of the lower end of the rectum and anal 
canal. The success of this operation depends upon the primary 
union of the parts. If this fails, there is likely to be an increase 
of the prolapse and incontinence of faeces. 

Treatment of Prolapse in the Third Degree. — As 
this condition depends upon the giving way of the superior 
supports of the rectum, or upon an abnormally long meso- 
sigmoid, the means for relief must be very different from those 
used for the first and second degrees of prolapse, but the 
exciting causes must be removed, if any exist, as in those of 
the first and second degrees; if a stricture, dilate it, or resect. 
While necessary to remove these before attempting to restore 
the superior rectal supports, no permanent relief can be looked 
for until the latter are restored. Very decided temporary 
relief may also be afforded to those suffering from prolapse 
of the third degree, by the daily introduction of a long Wales 
bougie, at a stated time before the daily evacuation, by which 
the bowel is carried back in position and its movements greatly 
facilitated. 

As shown, prolapse of the third degree is due principally to 
an abnormally long mesosigmoid ; the best means for correct- 
ing this is by drawing up the sigmoid and rectum and attach- 
ing it to the abdominal wall. This is known as sigmoidopexy. 

Sigmoidopexy. — This operation consists in opening the 
abdomen between the umbilicus and pubis to the outer side of 



PROLAPSE OF THE RECTUM 



297 



the left rectus muscle. The sigmoid and rectum are now 
caught and drawn up until taut ; the parietal peritoneum is 
stripped back for half an inch from the edges of the abdominal 
wound when one of the longitudinal bands of the sigmoid is 
made to protrude between the inner edges of the wound for 
its entire length, and attached to it by a row of silk sutures 




Fig. 104. — Sigmoidopexy — showing method of placing the suspensory and other sutures 
when the gut is brought into contact with the parietal peritoneum. (Gant.) 



that are passed, first, through the lower edges of the wound 
on one side, then through the longitudinal band of the sig- 
moid, and out through the lower edge of the wound on the 
other side. This method of attaching the sigmoid the entire 
length of the abdominal wound has recently been recommended 
by Samuel G. Gant in his work on " Constipation and Intes- 
tinal Obstruction" (Fig. 104), and gives a much firmer attach- 



298 DISEASES OF ANUS, RECTUM, AND SIGMOID 

ment than the former method, where it was attached below 
the abdominal wound only. The abdominal wound should 
then be closed in the usual manner. 

The results of this operation for prolapse of the third 
degree are most gratifying, and the operation is also very 
satisfactory for aggravated cases of the first and second 
degrees, w 7 hen combined with some one of the methods recom- 
mended for narrowing the anal orifice, or of suspending the 
lower portion of the rectum from the sacrum as before 
recommended. 

Excision. — This operation is so likely to be attended with 
or followed by serious complications that it should not be 
undertaken unless the methods previously described have 
failed, or where the prolapse cannot be returned. In the latter 
cases, if the strangulation has resulted in sloughing, or gan- 
grene, the operation of excision, although very necessary 
under these conditions, yet is very likely to be attended with 
very serious risks of septic peritonitis. 

Where the prolapse has been due to organic stricture, which 
protrudes with the prolapsed bowel and is at the lowest point 
of the prolapse, the whole may be excised, and thus the stric- 
ture and the prolapse can be relieved by the same operation. 
The other conditions which seem to justify excision of the 
prolapse are neoplasms, involving the entire thickness of the 
rectal wall, and adhesions, which prevent the reduction of 
the prolapse. 

Excision is only adapted for the relief of aggravated forms 
of prolapse of the first and second degrees. 

Of the many methods in use the one suggested by John 
H. Cunningham, Jr., of Boston, Massachusetts, seems to offer 
the most advantages and to be the simplest. It is as follows : 

Preparation for the Operation. — If ulcerations exist upon 
the prolapsed mass, or if the mass is acutely inflamed, let 
treatment be directed toward the improvement of these con- 
ditions before the operation is undertaken. The same is true 
of foul vaginal secretions, and of certain cases of eczema of 



PROLAPSE OF THE RECTUM 299 

the buttocks. A light diet and purging of the bowels is to be 
instituted at least two days before the operation, so that the 
bowel will be free from contents. Just before coming to the 
operating table, let the lower bowel receive a copious irriga- 
tion of 4 per cent, boric acid solution, and made to return. 
The vagina should be flushed in a similar manner. 

Operation. — The patient is placed in the lithotomy posi- 
tion, with the buttocks well over the end of the table. The 
protruding mass and the surrounding parts are made clean by 
soap and water and alcohol and the vagina packed with 
sterile gauze. 

The protruding mass is covered with sterile gauze and 
drawn outward. The rectal sphincters are usually so dilated 
that they cannot be defined. An incision is made with a knife 
at a point three-quarters of an inch from, and parallel with, 
the anal margin. This incision will usually be beyond the 
internal sphincter. Let it be carried through all the layers 
of the gut, thus opening into the pocket of the peritonaeum 
beneath. A pair of scissors now continue this incision around 
the whole circumference of the protruding mass (Cunning- 
ham, Fig. 105). The edges are widely retracted, as a loop of 
intestine may be within the peritoneal pouch. If so, it should 
be forced back into the abdomen before the cut is continued. 

This incision complete, the outer layer of the protruding 
mass is rolled inward by pulling the cut edge outward and 
rolling the mucous-membrane surface inward, thus doubling 
the length of the protruding gut (Cunningham). The gut 
is drawn outward until taut, and a clamp with flexible 
jaws placed as high as possible. The hemorrhage from the 
cut end of the intestine will thus be arrested. This hemor- 
rhage about the margin is usually an ooze; if, however, there 
are bleeding vessels in it, they should be snapped but not tied. 
The protruding gut is turned upward and the mesentery of 
the rectum inspected, when vessels which bleed considerably 
and require ligation will usually be found. It is important to 
control all hemorrhage from the mesentery, as intra-abdominal 



300 DISEASES OF ANUS, RECTUM, AND SIGMOID 

hemorrhage will otherwise result, following the completion 
of the operation. The gut having been drawn outward until 
taut, the clamp having been placed on the gut as high as 
possible, and the hemorrhage having been controlled, the 
distal portion of the gut is removed by a knife about one- 
half inch beyond the clamp (Cunningham, Fig. 106). 




Fig. 105. — Shows the incision three-quarters of an inch from the anal margin. The scissors 
are in position to continue the incision around the full circumference of the mass. 

It remains now to unite the cut edges of the distal portion 
of gut beyond the clamp to the proximal portion surrounding 
the anus. This has been done by a buttonhole stitch of No. 2 
chromatic cat-gut, each stitch being made to include at least 
a quarter of an inch of each cut portion of gut (Cunningham. 
Fig. 107). The stitch is made to unite all the layers of the 



PROLAPSE OF THE RECTUM 



301 



cut ends until the clamp is reached, when the clamp is removed 
and the small space previously occupied by it included in 
the sutures. The end of the suture is tied to the end made by 
the first knot, and union is complete, the hemorrhage from 
the cut gut being controlled by the buttonhole suture. 




Fig. 106. — Shows clamp applied to the gut as high as possible after gut has been drawn 
taut. The knife is cutting off the gut one-half inch beyond the clamp. 



A piece of rubber tubing four inches long is surrounded 
by iodoform gauze and made sufficiently large to fill the gut 
entirely, at the point of suture. This is placed within the gut, 
its passage being facilitated by smearing it with boric acid 



302 DISEASES OF ANUS, RECTUM, AND SIGMOID 

ointment. The packing is removed from the vagina and 
replaced with iodoform gauze. A self-retaining catheter may 
be placed in the bladder and siphon drainage established if it 
is deemed best. A suitable dressing should be applied to the 
perinaeum. 

After-Treatment. — Let the patient be kept on a light 
diet, and pil. opii. gr. I given night and morning to prevent 




Fig. 107. — Shows the position of the gut distal to the clamp being sutured by a button- 
hole suture of No. 2 chromic catgut to the border of gut surrounding the anal margin. The 
end of the suture at the first knot is left long to be tied to the other end of the suture when 
the anastomosis is complete. 



the bowels from moving. If siphon drainage of the bladder is 
not employed, let the patient be catheterized at regular inter- 
vals for several days. The rectal plug must be left in position 
for a week, providing the local condition remains satisfactory. 
After its removal the rectum is to be irrigated with 4 per cent. 



PROLAPSE OF THE RECTUM 303 

boric acid solution by means of a glass syringe, the amount 
being never more than two ounces at a time for fear of causing 
a desire to evacuate the fluid. With each injection the fluid 
is sucked out. With the bowel thus cleansed, one-half ounce 
of iodoform emulsion is injected and allowed to remain. 
This procedure should be performed once daily, provided the 
local condition remains clean. If not so clean, the procedure 
should be practised several times daily. It is desirous to pre- 
vent the bowels from moving for ten days, unless symptoms 
arise which necessitate a movement before this time. If so, 
inject four ounces of oil into the rectum to soften the fecal 
masses, and administer a purge. After the movement the 
iodoform emulsion should be injected. 

Keep the patient under observation for a year or two in 
order to detect any contraction at the point of suture. If 
this be detected, dilate by rectal bougies. 

Complications of Prolapse. — Jerome M. Lynch, of 
New York, reported a very interesting case of " Prolapse of 
the Uterus, Vagina, and Rectum, with Multiple Adenoma of 
the Rectum and Sigmoid and a Diverticulum of the Sigmoid," 
to the American Proctologic Society, June, 1909, in a woman 
aged seventy-one on whom he operated successfully. He 
removed the uterus and adnexa, after which the broad and 
round ligaments of each side were sewed together, in order 
to strengthen the pelvic floor. The sigmoid was next sus- 
pended to the abdominal wall, and the abdomen closed. The 
rectum was now excised, after the method of Mikulicz, as 
modified by Tuttle, an end-to-end anastomosis being done. 
The patient made an uneventful recovery, both the abdominal 
and rectal wounds healing by first intention. The following 
illustrations show the conditions before and after the operation 
(Figs. 108, 109). 

Other complications of prolapse of the rectum have already 
been alluded to and described, such as neoplasms, whether 
attached superficially to the mucous membrane or those involv- 
ing all the coats of the bowel, inflammatory conditions, 



304 DISEASES OF ANUS, RECTUM, AND SIGMOID 

strangulation and hernia. There are a few that have not been 
referred to, such as dysenteric inflammation, or infectious 
proctitis in children, as distinguished from ulceration due to 
exposure and friction of the mucous membrane in old cases 
of extensive prolapse. In the first class of these cases the 
dysenteric ulceration is frequently a cause of the prolapse and 
a subsidence of it will generally result in the relief of the pro- 




Fig. 108. — Prolapse of the uterus, vagina, and rectum, with multiple adenoma of the 
rectum and sigmoid, and a diverticulum of the sigmoid (before the operation). 



lapse, whereas the second form is a -result of the prolapse. 
The latter cases have already been alluded to. The former 
are best relieved by sponging off the prolapsed mucous mem- 
brane with warm and mild antiseptic and astringent solutions, 
after w T hich the prolapse is to be reduced and held in position 



PROLAPSE OF THE RECTUM 305 

by compresses, strapping of the buttocks, and confining the 
patient to the recumbent position, with feet and hips well 
elevated. The tenesmus should be relieved by appropriate 
doses of opium. 

Other complications are hemorrhage from the prolapsed 
mucous membrane, best controlled by weak solutions of supra- 
renal extract, and confinement to the recumbent posture. Cold 
is not to be applied for this purpose in these cases, on account 
of its liability to be followed by slouching. 




Fig. 109. — Prolapse of the uterus, vagina, and rectum, with multiple adenoma of the 
rectum and sigmoid, and a diverticulum of the sigmoid (after the operation). 

Age should not be considered a contra-indication against 
attempts at permanent relief of prolapse. 

Another complication may be due to the invagination of 
the whole of the large bowel, and in some instances of a 
portion of the small intestine also, in which the invaginated 
portion either protrudes into the rectum, simulating the third 
degree of prolapse of that organ, or the invaginated portion 
may even protrude through the anal margin. I saw a case of 
this description resembling the third degree of prolapse at St. 
Joseph's Hospital, May, 1908. The case was referred to me 
20 



306 DISEASES OF ANUS, RECTUM, AND SIGMOID 

as coming under my service in rectal surgery, but I recognized 
it as no true prolapse of the rectum and. referred it to one of 
the general surgeons on the staff, who upon opening the abdo- 
men found that the invagination involved first about six 
inches of the ileum into the caecum, the caecum into the ascend- 
ing colon, and the entire large bowel, including the sigmoid, 
was invaginated and prolapsed into the rectum. It was 
impossible to release the invaginated bowel, so the whole of 
the portion was excised and an anastomosis made between 
the ileum and the rectum. The condition had existed for 
three or four days, and consequently the patient was suffering 
very much from shock when operated on, and died at the 
end of twenty-four hours. 

Rupture of the Hernial Sac. — The last of these com- 
plications to be mentioned is rupture of the hernial sac through 
the rectal wall. Kelsey (" Diseases of the Rectum," 4th ed., 
page 240) gives a most interesting collection of cases of this 
kind. 

This accident may occur spontaneously during straining 
while at stool, so common and pronounced in these cases; 
from vomiting; from lifting heavy weights, or through efforts 
at reduction of the prolapse and hernia. 

If the rupture occurs while the bowel is prolapsed, the pro- 
trusion of the small intestine or other contents of the hernial 
sac will be readily recognized. The prolapse is likely to be 
spontaneously reduced after the rupture takes place. If it 
occurs when the bowel is not prolapsed, it will not likely be 
recognized except through the general symptoms, such as acute 
pain, which is followed by collapse and shock. This should 
lead to an examination of the rectum, when the presence of 
the small intestine or sigmoid would readily be recognized. 

The primary conditions which lead to this accident are 
the result of changes in the rectal wall, brought about by the 
abnormal conditions incident to the prolapse, which weaken it 
very materially. There may be marked extravasation of blood 
between the mucous and muscular coats of the bowel, following 



PROLAPSE OF THE RECTUM 307 

the rupture. If the case is seen soon after the rupture, the 
protruded bowel must be properly cleansed with sterile water, 
returned, and the rent sewed up. The results are not so 
serious, but if allowed to remain down any length of time the 
protruding intestine is likely to become strangulated. 

Great care must be taken in returning the prolapsed intes- 
tine. It should be carefuly washed off with a warm saline 
solution, and when replacing it the physician should be sure 
that it is returned into the pelvic cavity, and not simply pushed 
back into the rectum. 

If the protruding intestine is gangrenous when seen, let 
the gangrenous parts be excised and an end-to-end anasto- 
mosis done. The intestine may now be returned and the rent 
in the rectum closed, by first stripping back the mucous mem- 
brane from the edges of the wound, drawing the serous edges 
together, and uniting them by a running suture ; the mucous 
edges are now drawn together and united by a second row of 
sutures. 

It would be well to take advantage of this opportunity 
to permanently relieve the prolapse by doing a sigmoidopexy, 
as before described in this chapter. Both of these procedures 
can be done w T hile the patient is under the anaesthetic for the 
rupture of the hernial sac. 



CHAPTER XII 
STRICTURE OF THE RECTUM 

Stricture of the rectum consists of a narrowing of its 
lumen by an infiltration and subsequent contraction of its 
walls, but does not include a narrowing of its lumen by pres- 
sure from without, or by obstruction of its calibre by growths 
or by foreign substances from within. This infiltration does 
not necessarily imply a previous abrasion of its surface, as 
will be seen from strictures following secondary and tertiary 
syphilitic inflammation of the submucous connective tissue 
of the rectum, as in the formation of gumma, or the involve- 
ment of the circular bands of fibrous tissue that enter into the 
formation of Houston's valves by a similar form of syphilitic 
inflammation, and which may result in a valvular stricture 
of the rectum. This may be confined only to its mucous and 
submucous coats, or may involve all the coats of the bowel. 

The different degrees of constriction have given rise to 
the following subdivisions, viz., annular, tubular, and linear. 
These, however, merely indicate the extent of the infiltration 
and the form it assumes, regardless of its character. Any 
form of chronic inflammation of the rectal walls is liable to 
be followed by infiltration, which thickens the walls and 
narrows the lumen. 

Certain forms of inflammation, due to a specific cause, 
such as syphilis and tuberculosis, are more likely to be fol- 
lowed by excessive infiltration, and in certain individuals there 
is unquestionably a greater tendency to this fibrous infiltration 
than in others. It is therefore unnecessary to subdivide stric- 
tures of the rectum by their etiological factors as generally 
done, remembering that it is only the extent and probably 
the density of the infiltration influenced by them. 

308 



STRICTURE OF THE RECTUM 309 

There is one exception to the definition we have given 
above of stricture of the rectum, namely, spasmodic stricture 
of the rectum, which, however, is a functional and not an 
organic constriction. 

The different causes giving rise to stricture of the rectum 
may be thus classified : congenital, intramural neoplastic, 
spasmodic, and inflammatory. Any of these causes existing 
in any part of the rectum, or even if confined to the rectal 
valves, may give rise to stricture. 

Congenital Strictures. — These have already been consid- 
ered under the head of malformations, although frequently 
they pass unobserved into adult life, two such cases having 
been reported to the American Proctologic Society, June, 
1909, by Louis Hirschman, of Detroit, Michigan, where in 
two females the rectum opened into the vagina by a narrow 
constricted canal, which served the purpose of the normal 
anal opening until adult life, when they presented themselves 
for a correction of the abnormality before entering into mari- 
tal relations. Such cases may also continue unobserved until 
they present themselves for the relief of constipation, when 
an examination shows the true nature of the cause, hence the 
necessity of a thorough examination of all such cases before 
undertaking treatment. The stricture in such cases, where 
the patient has been able to get along for some years with so 
little trouble is likely to be at the juncture of the anus with 
the rectum, due to an incomplete union of the two, or in the 
rectovaginal variety of the same, which are the only two 
varieties of such abnormalities where the patient can get on 
for such a length of time with so little trouble. 

Treatment. — The permanent relief of such cases is only 
accomplished by the application of the radical measures before 
recommended under the head of such abnormalities. 

Intramural neoplastic stricture is one that narrows the 
lumen of the bowel by increasing the thickness of its walls 
by a new growth, as, for instance, sarcomata and carcinomata, 
especially the scirrhous variety of the latter. Its subsequent 



310 DISEASES OF ANUS, RECTUM, AND SIGMOID 

growth from the mucous surface of the bowel into its lumen 
is only an obstruction, not a stricture. This form of stricture 
will be treated under the head of Malignant Growths. 

Spasmodic Strictures. — A spasmodic stricture only exists 
in response to a reflex irritation; and only continues so long 
as the irritation is kept up, and is not attended with organic 
changes. In the notable case cited by Cripps (" Diseases of 
the Rectum and Anus," Fig. 46, page 207) and also a similar 
one reported by Ball, the spasmodic contraction of the circular 
muscular fibres, which resulted from the irritation of the 
existing ulcer, relaxed when the irritation was removed ; there- 
fore, the stricture was only functional. This condition must 
not be confounded with that found two years later in the 
same patient, when the ulcer had healed and a permanent 
organic stricture existed. The latter condition of the stricture 
w r as unquestionably due to the cause that exists in all organic 
strictures, namely, the formation of scar tissue following the 
healing of the ulcer, and was not due to any permanent short- 
ening of the circular muscular fibres resulting from the spas- 
modic contraction caused by the reflex irritation of the ulcer. 

Inflammatory strictures are those that result from simple, 
traumatic, tubercular, syphilitic, or any form of inflammation 
and ulceration involving the tissues beneath the mucous mem- 
brane. Any form of ulceration likely to be followed by scar 
tissue and infiltration of the submucosa will be followed by a 
stricture to a greater or less extent. This will occur in any 
part of the rectum where there is submucous tissue, including 
the valves of Houston. 

I mention the different causes giving rise to stricture of 
the rectum because certain ulcerations, such as tubercular and 
syphilitic, are not only more likely to be followed by stricture 
but even give rise to aggravated forms of it. 

Location. — The site of the stricture depends entirely upon 
the primary lesion causing it; no one portion of the rectum, 
therefore, is any more liable to stricture than another, except 
those parts that are more susceptible to injury. 



STRICTURE OF THE RECTUM 311 

Simple Inflammatory Strictures. — These may result from 
any abrasions or ulcerations of the rectal mucous membrane 
sufficient in extent to involve the submucosa. In some cases 
all appearance of the primary sore in the nature of a scar 
on the surface may have disappeared, yet a diffuse inflamma- 
tory condition may have involved the submucosa, which results 
in a fibrous infiltration and the formation of a stricture to a 
greater or less degree. Such a diffuse and inflammatory con- 
dition of the submucosa may also extend from a blind fistula 
into the surrounding submucous tissue, and be so extensive 
as to narrow the lumen of the rectum, causing a stricture. 
This may occur without any involvement of the mucous mem- 
brane of the rectum. Inflammatory conditions in the pelvis 
originating in the uterine appendages, or in the prostate, may 
also extend to the cellulonbrous layer which surrounds the 
rectum, resulting in extensive deposits of fibrous tissue and 
giving rise to stricture of the rectum. 

The fact shown above, that the production of a stricture 
depends upon an involvement of the submucosa in the inflam- 
matory process, explains why the more superficial catarrhal 
ulcerations rarely if ever result in stricture. 

Traumatic stricture is one due to injury to the rectal wall 
of such an extent as to result in inflammation, ulceration, or 
necrosis, as the healing of wounds by granulation, that result 
from surgical operations, involving the submucosa ; prolonged 
and undue pressure by the fetal head during labor; abrasions 
by foreign substances from within and without; the necrotic 
action of certain drugs, introduced into the tissues of the 
rectal wall for the destruction of certain growths, such as 
hemorrhoids; from the sloughing that may result from a 
strangulated hemorrhoid or from a prolapse of the rectum, 
or from any traumatism that may result in ulceration and 
the formation of cicatricial tissue. Remember, when operating 
for hemorrhoids, the peculiar susceptibility of certain indi- 
viduals to the formation of fibrous tissue following any injury 
to the submucosa. 



312 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Tubercular Stricture. — That tubercular ulceration of the 
rectum and the anal canal may not only result in stricture but 
in very pronounced forms of it, is now proven beyond all 
doubt by the frequent finding- of giant cells and tubercular 
bacilli in the scar tissue of strictures. Until recently it was 
thought that primary tubercular ulceration of the rectum was 
rare, and that when it did occur it was so soon followed by 
a general infection that there was rarely an opportunity for 
the deposit of sufficient fibrous tissue around the ulcer to 
result in any narrowing of the lumen of the bowel. 

Frequent microscopical examinations of the scrapings 
from ulcers, abscess cavities, and fistulous tracts have demon- 
strated the presence of tubercular bacilli in many cases where 
there were no pulmonary or general symptoms to indicate the 
presence of the disease. These findings, taken in connection 
with the extensive fibrous deposits often found around such 
tracts, would add additional weight to the other evidence that 
such is not an infrequent cause of stricture of the rectum. 

Referring- again to tubercular ulceration, as a cause of 
stricture of the rectum, Mitchell, Hartmann, Toupet, and 
others (Tuttle, " Diseases of the Anus, Rectum, and Pelvic 
Colon," page 469) have demonstrated these same character- 
istics, and thus proved beyond the shadow of a doubt that 
tuberculosis may result in the formation of true fibrous stric- 
ture of the rectum, without the ulcers having healed. 

Syphilitic Stricture. — I believe the same rule applies to 
syphilitic strictures as to the other varieties before mentioned 
in this chapter, namely, that they result from a local ulcera- 
tion involving the submucosa, with the addition of certain 
peculiar characteristics belonging to this disease, such as pre- 
disposition to the formation of nodular or gummatous enlarge- 
ments around the blood-vessels, and the endarteritis within. 
These special characteristics are attended with an extensive 
infiltration of fibrous tissue following syphilitic ulceration, 
hence the frequent occurrence of extensive syphilitic, tubular 
strictures. The extent of infiltration in these cases bears no 



STRICTURE OF THE RECTUM 313 

relation to the size of the ulcer giving - rise to it; on the con- 
trary, such ulceration is frequently so slight as to pass 
unnoticed, and for that reason patients giving a history of a 
primary syphilitic sore should be carefully examined for sec- 
ondary ulceration of the rectum whenever they show any 
symptoms of rectal irritation. The importance of recognizing 
this condition early is, that while this fibrous deposit is in its 
embryonic state it is soft and yielding, and by the use of 
proper measures, such as frequent dilatation of the rectum 
with bougies, and the use of antisyphilitic treatment, the sub- 
sequent contraction and formation of a stricture may be 
prevented. 

While the weight of clinical evidence supports the views 
expressed above, I do not think it conclusively proven that all 
cases of syphilitic stricture of the rectum can be accounted for 
by a previous ulceration of its mucous and submucous coats, 
or that a certain number of cases may be accounted for by 
the theory, propounded by Fournier in 1876, of an interstitial 
hyperplasia ending in a fibrous degeneration, and persistent 
contraction of the walls of the gut, without any previous 
ulceration. Tuttle (" Diseases of the Anus, Rectum, and 
Pelvic Colon," page 471) asserts that he is convinced from 
the histories of those cases of true anorectal syphiloma that 
have come under his notice, that they have been preceded by 
symptoms of ulceration of the mucous surface of the bowel. 
We are convinced, however, that when such cases are watched 
carefully from the time of the primary lesion ulceration of 
the mucous and submucous coats of the rectum will always 
be found to precede syphilitic stricture. 

Pathology of Stricture. — There is localized thickening 
of the mucous membrane and loss of the normal elasticity of 
the rectal wall, which has a dense leathery feel, and the mucous 
membrane is generally ulcerated. When the ulceration has 
healed, the mucous membrane is dry and loses its smooth, 
glistening appearance, which is due to the loss of its goblet- 
cells. When ulceration is present the surface is bathed in a 



314 DISEASES OF ANUS, RECTUM, AND SIGMOID 

mucopurulent discharge which is sometimes sanious. In old 
cases, Avhere the stricture is quite tight, there are likely to be 
two points of ulceration, one above and the other below the 
stricture. The one above, due to the irritation and pressure of 
fecal matter, which collects at that point, is a simple necrotic 
ulcer ; the one below is the type that produces the stricture. 

Fistulas are frequently found beneath, the mucous mem- 
brane, leading downward from the stricture, and extending 
outside into the perirectal tissues. 

The characteristic pathological changes to be looked for 
in all cases of syphilitic stricture are the nodular develop- 
ments about the arteries and veins, the endarteritis, and the 
finding of the Spirochceta pallida. In connection with the 
above findings the previous history of the patient should 
always be given due consideration. 

Symptoms. — Passing over symptoms incident to the pri- 
mary lesion which finally result in stricture, as they belong to 
the stage of ulceration of the rectum before treated of, I 
point out that not until the stenosis is well marked are the 
symptoms of stricture of the rectum sufficient to attract the 
attention of the patient, or to cause him to seek advice from 
his physician. 

The first symptoms complained of are heaviness and weight 
in the rectal and sacral regions, frequent desire to urinate, 
and a gradual increasing tendency to constipation, with diffi- 
culty in having a stool. The gradual retention and constant 
accumulation of a certain portion of fecal matter that should 
be evacuated each day soon gives rise to irritation and sub- 
sequent ulceration of the mucous surface of the bowel above 
the stricture. Following close upon this, we have ulceration 
beginning in the mucous surfaces below the stricture, due 
to an impairment of the circulation by the compression of 
the fibrous tissue surrounding the vessels — a pressure necrosis. 
This ulceration below the stricture generally assumes the char- 
acter of the ulceration peculiar to the primary disease. The 
most important symptoms attending the ulceration are a 



STRICTURE OF THE RECTUM 315 

copious discharge of thin, mucopurulent matter, frequently 
tinged with blood, and frequent desire to defecate, often 
ineffectual, resulting only in straining and the passing of 
some mucus and blood. It is at this stage that the physician 
is likely to be misled with regard to two important condi- 
tions — first, by mistaking the above symptoms for dysentery, 
which has frequently been done by those who have been 
careless enough to make a diagnosis without examination; 
secondly, when there is an impaction of fecal matter above 
the stricture, the hard scybalous masses will set up sufficient 
irritation to give rise to what is apparently a watery diarrhoea, 
whereas, in reality, the stools are only made up of an excessive 
amount of the mucopurulent matter, colored by erosions from 
the fecal masses ; thus, what is apparently a diarrhoea is in 
reality an impaction. The characteristic symptom of the latter 
condition is the involuntary and constant discharge of these 
watery stools. One may always suspect the true nature of 
such a condition in connection with such a symptom, whether 
the accumulation is due to stricture or to simple fecal impac- 
tion. Both of these mistakes can be avoided by a careful 
digital examination. 

With regard to mistaking the early symptoms of stricture 
for those of dysenteric ulceration, it is doubtless due to such 
a mistake that stricture of the rectum has frequently been 
attributed to such a form of ulceration, whereas it is very 
questionable if a stricture of the rectum has ever resulted from 
such a form of ulceration, knowing, as we do, such ulcerations 
to be confined to the superficial part of the mucous surfaces. 

The amount and character of the discharge depends largely 
upon the character of the stricture. When syphilitic, the dis- 
charge will likely be very abundant, nearly always sanious, 
dark in color, and possessing a feculent odor. When due to 
simple or tubercular inflammation, the discharge is much less 
likely to be mixed with blood and is creamy white in color. 

Inflamed tags of skin, condylomata, papilloma frequently 
surround the anal margin in syphilitic strictures. 



316 DISEASES OF ANUS, RECTUM, AND SIGMOID 

The shape of the moulded stool in stricture has until 
recently been considered characteristic, but now it is known 
that its shape can only be modified by the stricture when the 
latter is close to the anal margin. 

When the stricture involves the sphincter, the infiltration 
of its fibres by fibrous tissue interferes with its action, giving 
rise to more or less incontinence. 

Dilatation and thinning of the wall of the rectum or sig- 
moid always occurs in the course of time just above the 
stricture, which, together with the ulceration previously spoken 
of, makes the danger from rupture of the bowel probable and 
calls for great care in the management of the case. 

Diagnosis. — While the history of the case and the symp- 
toms may aid materially in diagnosis, the only positive means 
is a digital examination when the stricture is within reach 
of the finger; when it is above this point, the pneumatic proc- 
toscope, together with the proper interpretation of the symp- 
toms, will generally be sufficient to enable the physician to 
arrive at a definite conclusion. Let great gentleness be exer- 
cised in examination, either with finger or proctoscope, in 
order to avoid risk of rupturing the diseased bowel. A 
bimanual examination will greatly aid the examiner when the 
stricture is high up, as will an examination per vaginum in 
women. All of the above means will be made much more 
effectual in strictures high up by the relaxing effect of a gen- 
eral anaesthetic. 

Very little definite information can be gained by the use 
of rectal bougies in these cases, and when they are used the 
greatest care should be taken. 

A former practice of introducing the whole hand into the 
rectum for the purpose of making a diagnosis in obscure cases 
cannot be too greatly condemned in these, as it offers no advan- 
tages over the methods just enumerated and is far more dan- 
gerous. When failure has attended the above methods in 
making a diagnosis for stricture high up in the bowel, an 
exploratory laparotomy for the purpose, and at the same time 



STRICTURE OF THE RECTUM 317 

for the removal of the diseased portion, is perfectly justifiable. 
The incision for this purpose should be similar in location to 
that for a left inguinal colostomy, as the latter may become 
the more justifiable means of relief. 

The differential diagnosis between benign and malignant 
stricture of the rectum is very important and, in some cases, 
difficult. This is far more likely to be the case with stric- 
tures high up; the nodular character of the malignant 
growth can generally be made out when low down. The age 
of the patient in a measure helps to differentiate between the 
two, as a malignant growth does not generally occur in per- 
sons under thirty-five years of age. The latter ordinarily 
runs its course in the death of the patient in two or three 
years, and is attended with the early loss of flesh and strength. 
The reverse condition exists in the benign form. The dis- 
charge in malignant strictures is likely to be very offensive, 
and generally of a dark grumous character, and of a prune- 
juice color. 

Whenever possible, a specimen from the growth or stricture 
should be obtained and examined microscopically, but not too 
much reliance placed upon the results, as it may be beyond 
the limit of the growth. 

In determining between the different varieties of inflam- 
matory strictures, the differentiation is most marked between 
syphilitic strictures and those due to other causes. In the 
former, they are rarely abrupt in making their appearance ; 
show a gradual funnel-like contraction, and have a bluish 
white cicatrix around the edges of its ulcers ; whereas in 
simple inflammatory strictures, they make their appearance 
abruptly, may be limited to only one side of the rectum, and 
are likely to occur near the anus. 

The scrapings from a tubercular stricture will generally 
determine its character by the presence of tubercle bacilli and 
giant cells. 

Treatment. — This may be divided into preventive, pallia- 
tive and operative. 



318 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Preventive Treatment.- — Of this I would say that much 
can be done to prevent the formation of a stricture if the case 
is closely watched, and the fibrous tissue kept well dilated in 
the early stages of its existence, best done at the close of the 
healing process of the primary sore, and immediately follow- 
ing it ; hence the necessity of dilating the anal canal for several 
weeks from the close of the first week following all operations 
for hemorrhoids, or of the healing of deep ulcerations. Simi- 
larly, all cases of syphilis seen in the primary stage should 
have their rectum examined repeatedly during the secondary 
and tertiary periods, for all ulcerations should be treated 
promptly both by local and constitutional means to make them 
heal as promptly as possible, and following the healing of these 
ulcers the rectal wall should be dilated, probably most success- 
fully by inflation with air every alternate day, for five or six 
weeks. 

Palliative Treatment. — The success attending this depends 
upon the stage of development when it is begun. If before 
the fibrous tissue has become fully organized, and before it 
has lost its elasticity, then much can be accomplished by 
gradual and careful dilatation, and if syphilitic in origin, 
the gradual dilatation may be supplemented by antisyphilitic 
constitutional treatment. If, however, the stricture is hard, 
dense and unyielding, little can be expected from either of 
the above methods, though much can be done, however, even 
at this stage for the comfort of the patient, by so regulating 
his diet as to give him a soft and easy stool. Let the diet 
consist largely of vegetables and fruits, even at the risk of 
irritating the ulcerated surfaces about the stricture if they 
exist. The scybalous masses which are so likely to form 
above the stricture must be prevented, if possible, and if 
laxative food fails to do so, then it should be supplemented 
by the administration of olive oil by mouth in half-ounce doses, 
several times daily, either with lemon juice or in salad dressing. 

Electrolysis. — Very much has been claimed for the 
action of electrolysis in dilating strictures and for stimulating 



STRICTURE OF THE RECTUM 319 

the absorption of the fibrous tissue. After a thorough trial 
of this method I found results gained in dilating the stricture 
to be entirely temporary, the electrode seeming" to pass more 
easily when the current was on than when not; but repeated 
introductions of the olive-shaped electrode with the current 
did not make it pass in any easier without the current than it 
did before the latter was first used ; nor did I find any appre- 
ciable difference at the end of several months' use of electro- 
lysis in the amount of fibrous tissue that composed the 
stricture. 

Gradual Dilatation. — Much more can be said in favor 
of gradual dilatation of a stricture by bougies, from a pallia- 
tive standpoint, than from electrolysis, as by this means 
patients may frequently be enabled to keep the rectum and 
sigmoid emptied with considerable comfort and for some time. 
Do not forget that the use of this palliative means is attended 
with considerable risk of rupture of the bowel, hence great 
care should be taken in its use. 

The bougie used for this purpose should be soft and fairly 
flexible, the Wales type being the best on the market. Use 
great gentleness and little force in its introduction, and it is 
best to have the different sizes, certainly from No. 4 to No. 10, 
in order that you may not be tempted to introduce a No. 8 
bougie into a stricture with the calibre of a No. 5. Let the 
bougie be introduced every day, or every alternate day, and 
remain in the stricture from five to ten minutes each time. 

Stricture situated below the deflection of the peritonaeum 
(that is, within five inches of the anal orifice) is best adapted 
to the use of this palliative measure, as the danger from rup- 
ture of the walls of the bowel below that point are not nearly 
so serious. I would not advise the use of a bougie for gradual 
dilatation of a stricture above this point, except in the hands 
of the most experienced operators. 

In cases of stricture of the anal orifice, especially those 
following operations for hemorrhoids, I recommend the olive- 
shaped, hard-rubber dilator, which comes in four sizes, No. 1 



320 DISEASES OF ANUS, RECTUM, AND SIGMOID 

being the smallest. The No. 3 is as large as will be found 
necessary (Fig. no). They can be used by the patient with- 
out any risk, after having been instructed by the physician. 

Rapid Dilatation. — In the light of present experience, it 
would be only safe to use this means in cases of stricture well 
below the deflection of the peritonaeum, especially those follow- 
ing operations for hemorrhoids. It should always be done 
under the influence of a general anaesthetic. There have been 
many devices suggested in the way of rectal dilators, such as 
Sims's, Durham's, Mathews's, Martin's " coactor," and several 
others, but I advise that any stricture of the rectum that con- 
tains more fibrous tissue than can be stretched or torn with 
the fingers, or a Kelly dilator, be cut with a knife. 




Ftg. 1 10. — Olive-shaped hard-rubber dilators. 

Operative Treatment. — The operative methods that are 
generally suggested for the relief of stricture are partial and 
complete proctotomy, colostomy, and excision. 

Partial Proctotomy. — Partial or internal proctotomy may 
consist either in nicking the margins of an annular stricture, 
or of an internal complete division of it. The former is quite 
simple and devoid of any special risk, but the latter is very 
dangerous on account of the liability to infection, especially 
if the stricture is located high up in the rectum, and unless 
complete drainage with frequent irrigations can be secured. 
I do not advise the latter procedure except in cases of valvular 
stricture, after which a drainage-tube should be kept in the 
rectum and the same irrigated at least twice daily. 

Complete Posterior Proctotomy. — This consists of an 
incision from just above the stricture, through the stricture, 
and continued through all the coats of the bowel including 



STRICTURE OF THE RECTUM 321 

the sphincters and tissues posteriorly to within a short dis- 
tance of the coccyx. By keeping the line of incision in the 
posterior median line there will be very few of the fibres of 
the external sphincter cut. Before this incision is made the 
rectum below and if possible above the stricture should be 
thoroughly irrigated with an antiseptic solution, preferably 
i-iooo of bichloride of mercury. After the stricture and the 
tissues between it and the coccyx have been divided, a No. 10 
or Xo. 12 Wales bougie must be passed well up into the sig- 
moid to assure the operator that there is not a second stricture 
higher up, a possibility to be borne in mind. When there are 
fistulous tracts running around the stricture, opening either 
above or below it, open them all up, and incise the stricture 
at the same time. This may serve the purpose of a posterior 
proctotomy. Following the operation the wound must be 
well packed with plain sterile or iodoform gauze, a drainage- 
tube having first been placed in the rectum, with its upper end 
several inches above the stricture, and its lower end protrud- 
ing several inches beyond the anal margin, and this kept in 
from thirty-six to forty-eight hours. Let the removal of the 
first packing be followed by irrigations of sterile water twice 
daily, with light packing, the large drainage-tube still remain- 
ing for several days. After this, take out the drainage-tube 
and packing and irrigate the wound with sterile water twice 
daily, and pass a No. 10 Wales bougie into the bowel after 
each irrigation, allowing it to remain for five minutes each 
time. Continue this treatment until the posterior wound is 
closed completely, after which the Wales bougie should be 
passed once a day for a year following, or as long as there is 
any tendency to contraction of the rectum. 

There is some danger of infection following this operation, 
which should be met promptly by immediately removing the 
packing and instituting frequent, warm, antiseptic irrigations. 
Should the hemorrhage be excessive, immediately after the 
operation, it can be controlled best by packing the wound 
tightly. 
21 



322 DISEASES OF ANUS, RECTUM, AND SIGMOID 

This method, although not curative in its results, may be 
found very useful in allowing the patient to have fairly satis- 
factory evacuations, as long as he will persist in the regular 
passage of the bougie at the regular intervals. It is only 
applicable to those cases where excision is contraindicated, and 
where the stricture is within five inches of the anal margin. 

Colostomy. — Colostomy may frequently be employed in 
cases of stricture of the rectum for the following purposes : 
to insure a more thorough irrigation of the ulcerative bowel 
below ; for temporarily diverting the fecal current, thus reliev- 
ing the ulcerated bowel from the irritation incidental to its 
passage over it; or as a permanent artificial anus; and in 
cases of tight inoperable strictures of the rectum for tem- 
porarily diverting the fecal current preceding and immediately 
following an excision of the rectum. For either of these 
objects, left inguinal colostomy will be found very useful, 
and should be used much more frequently than it has been 
for these cases. 

Excision. — Excision of rectal strictures is only applicable 
to appropriate cases. Do not let it be done in cases attended 
with extensive ulceration of the mucous membrane, or with 
suppurating fistulous tracts. The technic of the operation 
should be most complete, as success so largely depends upon 
this. The sigmoid and rectum must be emptied by gentle 
means, three or four days before the operation is undertaken, 
and for the same length of time the evacuations should be 
followed by frequent irrigations with antiseptic solutions, 
preferably 1-5000 of mercury bichloride. The excision may 
be done by one of two methods, either the perineal or the 
sacral, the choice of which depends upon the location of the 
stricture. If the stricture is within 2^ inches of the anal 
margin, the perineal route is to be chosen ; if above this point, 
the sacral one. 

Perineal Method. — If the sphincters are involved in the 
stricture, dissect them out, together with the rectum, by an 
incision extending entirely around and to a point at least two 



STRICTURE OF THE RECTUM 323 

inches above the stricture. If the sphincters and anus are not 
involved, a posterior proctotomy may be done, the incision 
extending up the rectum to a point just below the stricture. 
A circular incision is now made on the inside of the rectum, 
just above the internal sphincter muscle, and extending through 
all the coats of the bowel. The rectum is dissected out to a 
point two inches above the stricture, as in the previous case, 
and cut off just above the stricture, its proximal end drawn 
down, and stitched to the border of the mucous membrane 
that was left just above the sphincters. The cut ends of the 
sphincter, divided in the posterior proctotomy, are now drawn 
together, its mucous edges being first united, and then the 
sphincter and the adjoining tissues are approximated and 
held in place by two deep silver-wire sutures. The posterior 
proctotomy wound is drawn partially together, and a drainage- 
tube and some slight packing are put in the lower angle of 
the wound and allowed to remain for several days, until there 
is evidence of union having taken place between the cut ends 
of the bowel. A large piece of rubber tubing is now intro- 
duced into the rectum for three or four inches, and allowed to 
protrude beyond the anal margin for the purpose of carrying 
off the gases and fecal matter from above, without infecting 
the wound. Let the bowels be confined for six or seven days 
with opiates, if necessary, and the patient put on liquid diet. 
If impossible to secure a sufficient length of bowel to pull down 
to the anal margin after excising the strictured portion of it, 
then you are justified in cutting the lateral ligaments opening 
into the peritoneal cavity and dividing the mesorectum suffi- 
ciently far up to allow the bowel to be drawn down and 
attached just above the anal margin. This latter procedure is 
not likely to be necessary in the cases that call for the use of 
the perineal route. 

The Sacral Method. — The sacral method is similar to 
Rydgier's modification of Kraske's operation for excision of 
the rectum, hereafter to be described under Extirpation of 
the Rectum. 



324 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Here is a case of excision of the rectum by the perineal 
method taken from my own case-book. It is a forcible illus- 
tration of extensive tubercular infiltration, and the good results 
obtained in this case show that such cases are not as hopeless 
as generally supposed ; on the contrary, the very presence of 
such an amount of fibrous tissue as to cause stricture is evi- 
dence of the successful resisting power of the individual against 
the disease. Whenever there is extensive infiltration surround- 
ing tubercular inflammatory processes, such cases offer the 
best results from operations, provided such barriers are not 
broken down, unless the entire diseased tissue can be taken out 
without the risk of infecting the surrounding healthy tissues, 
as in carcinoma. 

Case. — General history, from the family physician, Dr. 
Henry J. Hahn : R. F. W., came to me for treatment July 2, 
1908. Complained of having felt sluggish and feeble for sev- 
eral weeks. He thought he had malaria. Physical examina- 
tion showed no liver or splenic enlargement, and the examina- 
tion of the abdomen was negative. Lungs were clear, except 
for rough breathing over the left apex anteriorly and pos- 
teriorly, with prolonged expiration. Temperature reached its 
maximum, 10 1.5, on July 5, three days after I saw him, then 
it cleared up by lysis, and was normal within ten days from 
the onset. There is no cough now, only occasional clearing 
of the throat. 

He gave a history of having had a cough about eight years 
ago, which lasted for more than six months. This was fol- 
lowed a year later by an attack of purulent tonsilitis, the 
abscess rupturing spontaneously. About that time he lost 
fifteen pounds in weight, which he never regained up to the 
time of the operation. 

When the diagnosis of tuberculosis of the rectum was 
made I began the injection of tuberculin, using Koch's T O, 
beginning with a dose representing .001 mg. ; this was increased 
daily until he is at present taking 50 mg. without reacting. 



STRICTURE OF THE RECTUM 325 

Examination of the lungs December i, 1908, showed the same 
to be clear throughout. He has increased in weight thirty 
pounds. 

Special History. — About ten years ago his hemorrhoids 
were injected by a quack, presumably with a solution of car- 
bolic acid ; this was followed by excruciating pain and con- 
siderable swelling, which only subsided after several weeks. 
About one year afterward he was operated on by a general 
surgeon for stricture of the rectum, who did what appeared to 
be, from the scar tissue, a posterior proctotomy. Since that 
time the constriction has gradually increased until the lumen 
of the bowel at this point is only about half an inch in diam- 
eter. The most contracted portion of the rectum is about 
three inches from the anal margin, with the infiltration of the 
tissue growing less until it gradually disappears about one inch 
below the stricture. There are frequent attempts at stool, 
followed by the passage of a small amount of fecal matter, 
with considerable mucus, sometimes streaked with blood. 

Operation. — Under ether anaesthesia I operated by the 
perineal method. First, an incision was made posteriorly from 
just above the stricture through the sphincters at the posterior 
commissure down to the tip of the coccyx; a circular incision 
was then made through the entire thickness of the bowel, 
entirely around the rectum just above the internal sphincter; 
the rectum above this point was then dissected out to several 
inches above the level of the stricture. The resected portion 
of the rectum was now excised at a point just above the level 
of the stricture, and the proximal end of the bowel drawn down 
and sutured with chromicized cat-gut to the mucous mem- 
brane, which had been left by the first circular incision cover- 
ing the sphincters. The ends of the divided sphincter at the 
posterior commissure were brought together and sutured, first, 
with chromicized cat-gut, and these reinforced by a deeper 
silver-wire suture. The incision in the tissues, between the 
sphincter and coccyx, was left open to heal by granulation, and 
drainage-tubes were introduced through this incision on either 



326 DISEASES OF ANUS, RECTUM, AND SIGMOID 

side of the rectum; there was also a drainage-tube introduced 
anteriorly to the excised portion of the rectum wall. The 
latter was removed in three or four days, and the posterior 
tubes after a week or ten days. The results were all that 
could be desired, the proximal and distal ends uniting very 
promptly, and the posterior incision in about one month. 
There was very slight separation between the divided ends of 
the sphincter ani, not more than is generally found following 
an ordinary operation for fistula in ano, and he has perfect 
control over normal stools. Up to the present time, eight 
months from the date of the operation, there is not the slightest 
tendency to a recurrence of the stricture. 

The Gross Condition of the Specimen, — The length of the 
excised portion of the rectum was about three inches, and the 
infiltration was very extensive, including all the coats of the 
bowel, and also extending to a limited extent into the cellular 
spaces beyond. The naked-eye appearances were similar to 
those of syphilitic infiltration. 

Pathological Findings. — The examination of the specimen 
was made by Dr. Jose L. Hirsh. Here is his report : 

Examination of the tissues shows several areas of begin- 
ning caseation, and others with rather well-formed early 
tubercles ; other areas show considerable increase in fibrous 
elements. I take the condition to be tubercular stricture of 
the rectum. 

Results. — The results of this operation are not nearly so 
good as hoped for in the early days immediately following its 
introduction to surgery. The hopes of the early operators 
had been raised by a comparatively small mortality, about 
io per cent., but a longer observation of the cases showed a 
very large percentage of recurrences, almost as large in pro- 
portion as in complete proctotomy; besides there were quite 
a number of other very unfortunate sequelae, such as incon- 
tinence, prolapse, rectitis, and suppuration sufficient for them 
to wear napkins ; and stercoral fistula. A still more extended 
observation of these cases will probably warrant the statement, 



STRICTURE OF THE RECTUM 327 

that, barring- a certain amount of inconvenience due to ulcera- 
tion, small fistulse, or incontinence, 50 per cent, of these cases 
have been practically cured. These results show a decided 
improvement over the older methods of treating stricture by 
internal and complete proctotomy. 

Proctoplasty. — This is the effort to restore the normal 
condition of the margin of the anus, and the lower portion of 
the rectum, following great destruction of the tissues of these 
parts, which has been followed by large, dense cicatrices. It 
may be impossible to restore the calibre of the rectum, or the 
anal outlet, without resorting to some form of plastic opera- 
tion. No rule can be laid down for such work, but it will 
have to be left to the ingenuity of the attending surgeon to 
meet each case on its individual requirements. 

There have been cases reported where such defects have 
been corrected by taking large, triangular flaps from the but- 
tock, swinging them around into the space from which an 
extensive cicatrix has been removed, and suturing in this 
position. Skin-grafting has also played an important part 
in the restoration of these cases. 



CHAPTER XIII 
PRURITUS ANI 

It must be remembered before undertaking the considera- 
tion of this subject that pruritus ani is a symptom, not a 
disease. Broadly speaking, it may be said that pruritus or 
itching is due to an irritation, either direct, reflex, or con- 
stitutional. We will consider the part played by each one of 
these causes, and try to determine which one, if any, plays 
the most important part and is most causative in producing 
these symptoms. I do not doubt that constitutional causes 
may, in a certain number of cases, be a predisposing and in a 
certain very limited number the sole etiological factor, yet I 
think very few cases can be accounted for on such grounds. 
Among the constitutional causes are gout, uricaemia, and 
diabetes. 

Reflex Causes. — Reflex causes are those that result from 
an irritation that has been reflected from some other organ. 
The intestinal tract and the genito-urinary organs are most 
frequently at fault in these cases. I am sure pruritus ani 
much more frequently results from this class of causes than 
from the preceding or constitutional ones. Dismissing then 
further consideration of these two with the injunction that if 
no local cause for the symptoms can be ascertained after most 
careful and painstaking search (not complete without being 
made under the influence of a general anaesthetic), then the 
above possible causes must receive due and careful consid- 
eration. 

I know that in the large majority of cases a local cause 
can always be found to account for the symptoms, this view 
being, so strengthened by each year's additional experience 
that I now feel justified in taking such a decided stand in 
asserting that there are but few exceptions to this rule. 

Direct Causes. — These may be divided into external and 
internal. 



PRURITUS ANI 329 

External causes are such as affect the skin surface around 
the anal margin as far as the mucocutaneous border. Under 
this heading may be included pediculi, parasites, eczema, der- 
matitis, herpes, and erythema. The form of pediculi that are 
most likely to infect the anal border is the Phthirins ingninalis, 
or crab-louse. They can readily be gotten rid of by a liberal 
use of blue ointment or coal oil. Of the visible parasites that 
produce itching around the anus the trichophyton is the one 
most commonly found. This parasite is the cause of eczema 
marginatum. It is found in the superficial layers of the epi- 
dermis and is said to be highly contagious. A microscopic 
examination will always disclose its presence. The charac- 
teristic appearance of the fungus is that it contains very 
numerous spores or mycelia. The most satisfactory and 
certain remedies for their destruction, and at the same time to 
allay the itching, are ointments containing about 2 per cent. 
of acid salicylic and 3 per cent, of Calvert's carbolic acid. 

Herpes around the margin of the anus is not nearly so 
likely to produce pruritus ; it is readily recognized, and its 
treatment has already been alluded to. 

We believe that by far the most frequent local cause for 
pruritus ani is to be found in blind sinuses frequently origi- 
nating in ulcers at the bottom of the crypts of Morgagni. The 
likelihood of small, hard foreign bodies getting into these 
crypts and resulting in irritation and ulceration is very great, 
on account of their location, between the columns of Mor- 
gagni, with the open end of the crypt looking upward. This 
blind sinus may burrow in the tissues beneath the mucous 
and cutaneous surfaces of the anal canal and extend entirely 
around it, frequently with no evidence of any external open- 
ing. On account of the excessive moisture of the skin around 
the anal margin, which is so frequently found, especially in 
those cases where cracks and fissures are found between the 
anal folds of the skin, I am tempted to think that the blind 
sinus may sometimes relieve itself of its discharge through 
these cracks and fissures. I have been forcibly impressed 



330 DISEASES OF ANUS, RECTUM, AND SIGMOID 

recently by the frequency with which this blind sinus is found 
after a careful search. It may be found either by introducing 
a probe with its end bent at an acute angle into the crypt, as 
suggested by William Beach, of Pittsburg, in his paper on 
pruritus ani, read before the American Proctologic Society, 
June, 1909; or by a lateral incision, made through the skin 
and subcutaneous tissues just beyond the anal margin, and 
over the external sphincter muscle. A director or probe may 
be introduced through the incision, and the sinus felt for, and, 
if present, it can be followed to its internal opening at the 
bottom of the crypt. The author has had more success in 
tracing them in this manner than by that suggested by Beach. 

Charles Frederick Wallis, of Charing Cross Hospital, 
London, was probably the first to call attention to this factor 
in the etiology of pruritus ani, and T. C. Hill, of Boston, and 
William M. Beach, of Pittsburg, have since expressed similar 
views. 

Among the other local causes may be mentioned anorectal 
ulcerations, hemorrhoids, catarrhal conditions of the rectum 
and lower sigmoid, irritating vaginal discharges, thread- 
worms, congestion resulting from habitual constipation, the 
presence of smooth foreign bodies in the rectum, tumors of 
the rectum, and even of the adjoining organs. Thomas Cullen, 
of Johns Hopkins Hospital, Baltimore, cites a case of a very 
aggravated pruritus ani, which had lasted for some time and 
had resisted all forms of treatment, which was finally relieved 
promptly and permanently by the removal of a fibroid of the 
uterus. 

The dry, brittle condition of the mucocutaneous surface 
about the anal margin, frequently described as a symptom of 
pruritus ani, is associated with atrophic catarrh of the anus 
and rectum, while the moist, sodden, whitish condition of the 
skin around the anal margin is found in those cases due to 
blind sinuses. 

Symptoms. — The symptoms may almost be summed up 
in one word, itching, which predominates so largely over all 



PRURITUS ANI 331 

others that they are literally lost sight of. The itching is of a 
most tormenting and tantalizing character, in some cases 
almost driving the patient to distraction. It is generally worse 
at night, coming on after the patient is warm and comfortable 
in bed, although others are subject to it both night and day. 
In some it is produced by sudden changes of temperature, 
overwork, and anxiety. The skin surrounding the anus is 
commonly thickened, of a whitish appearance, or, in certain 
cases, as in those resulting from atrophic catarrh or syphilis, 
it is drv and scalv ; in either case sulci between the furrows 




Fig. hi. — Showing the thickened and cracked skin in pruritus ani. 

of the skin are cracked, and in the first class of cases exude 
a thin, clear, watery discharge. In either case the skin for 
some distance around the anal margin is denuded in numerous 
places by the finger-nails of the patient, giving it a blotched 
or barked appearance (Fig in). 

Treatment. — The remedies that have been suggested for 
the relief of the itching are innumerable, as have also been the 
surgical procedures, but we think since a local cause is so 
generally recognized the treatment hereafter will consist in a 
thorough search for and removal of it, without wasting so 
much time in the trial of the numerous remedies. 



332 DISEASES OF ANUS, RECTUM, AND SIGMOID 

The author thinks it best in the chronic cases, especially 
those attended with thickened and fissured skin, for the attend- 
ing physician to tell the patient from the very first how little 
hope there is for any permanent relief in local applications, 
and advise him to submit to a thorough search for the cause, 
under a general anaesthetic if necessary, and at the same time 
to have it removed if found. This recommendation would 
include the search for and the opening up of blind sinuses or 
fistulse, the removal of hemorrhoids, polypi, condylomata, the 
division of stricture, or the removal of any pathological lesion 
or foreign body that may be found. If intestinal parasites are 
suspected, they should be removed by means recommended in 
books on general medicine. A very simple remedy for the 
removal of thread-worms, as suggested by James P. Tuttle, is 
the injection into the rectum and drinking of liberal quantities 
of lime-water. 

When evidences of a reflex cause exist, it should be cor- 
rected at once, and while waiting for such a cause to be 
removed one of the local remedies hereafter to be recommended 
for allaying the itching should be used. 

When due to catarrhal proctitis or sigmoiditis these dis- 
eases should be treated according to the directions before given 
in the chapter on those diseases. 

Local Applications. — For allaying the pruritus, I give 
only such remedies which I know to be of special benefit. I 
have already mentioned those to be used in cases due to 
pediculi, eczema marginatum, and trichophyton. In the fol- 
lowing prescription it is recommended that Calvert's No. i 
carbolic acid should always be specified, as it has been found 
that other preparations of it are irritating to the skin : 

Ifc — Acid carbolic C. No. i gtt. xv 

Pulv. gum camphor 3ss 

Spr. rectificat q.s. 

Ungt. zinci oxidum q.s. 3ss 

M. ft. ungt. 

S. Apply before going to bed, and whenever 
necessary to allay itching. 



PRURITUS A1NI 333 

I£ — Pulv. camphor 3ss 

Spr. rectificat q.s. 

Ungt. aq. rosse Sss 

M. ft. ungt. 
S. Apply whenever itching. 

Lewis H. Adler, of Philadelphia, is very partial to the use 
of the ointment of the nitrate of mercury, in strengths varying 
from 10 per cent, to the pure ointment. He advises this as a 
curative measure to be tried in all chronic cases where no local 
cause can be found, or when no relief is given by their removal. 
He insists upon the application of the ointment daily by the 
physician himself, following the evacuation of the bowels. 
The parts should be thoroughly cleansed by him, the ointment 
spread upon gauze and applied to the parts and held in posi- 
tion by a T bandage. 

If the pure ointment produces much irritation, it is reduced 
in strength. Another very good application is the following: 

R — Chloral hydrate gr.xv 

Glycerina Bss 

M. ft. mixture. 
S. Apply when the parts are itching. 

Sometimes the application of comp. tr. benzoin, to be re- 
peated whenever necessary, will afford relief. 

In cases where no exciting local cause can be found, and 
which have resisted all local treatment, Sir Charles Ball (Brit- 
ish Medical Journal, Vol. I, page 113, January, 1905) has 
recommended the division of the sensory nerves supplying the 
affected parts, which is done under the influence of a general 
anaesthetic in the following manner : An elliptical incision is 
made on either side of the anus, about one-half to three- 
quarters of an inch from its margin, the incision beginning on 
either side of the perineal raphe, and being continued around 
the anus, to the coccygeal raphe. The incisions on each side 
are elliptical in shape, and do not meet anteriorly or posteriorly 
by at least three-quarters of an inch (Fig. 112). The inci- 



334 DISEASES OF ANUS, RECTUM, AND SIGMOID 

sion extends through the skin into the subcutaneous tissue. On 
both sides of the elliptical incision the skin is separated from 
the underlying tissues by blunt-pointed scissors, for one inch 
on the peripheral side, and to the mucocutaneous junction on 
the proximal side, also beneath the underlying flaps of the 
perinaeum both anteriorly and posteriorly. In doing this all 
the sensory nerves supplying the parts are divided (Fig. 113). 





Fig. 112. — Showing elliptical incisions 
each side of the anal margin. 



Fig. 113. — Showing one flap dissected 
back, which brings into view the nerve fila- 
ments to be divided. 



All the flaps are now allowed to fall in place, and their edges 
are stitched together with interrupted cat-gut sutures. A 
compress is applied, which is renewed twice in twenty-four 
hours, the wound being first sponged off* with a weak solution 
of bichloride; the patient is confined to bed, and the bowels 
are confined until the fifth or sixth day. By this time union 
of the parts should have taken place, when the itching will be 



PRURITUS ANI 335 

found to be relieved in a large majority of cases. I personally 
have done this operation a number of times, with about 75 
per cent, of cures. 

Thomas C. Martin, of Washington, D. C, who has sug- 
gested a modification of Ball's operation, has had even better 
results; a number of others equally good ones. This operation 
should be done under strictly antiseptic precautions, so as to 
secure primary union of the wound. Martin's modification 
of Ball's operation consists in the interruption of each of the 
lateral elliptical incisions at their centre, leaving a connecting 
link between the internal- and external flaps. 

Louis J. Krouse, of Cincinnati, Ohio, suggests still another 
modification of Ball's operation, giving the following reasons : 

" In order to derive the full benefit of Ball's original opera- 
tion, and still maintain the vitality of the flaps, it is imperative 
that the flap dissected from the underlying tissue should 
receive its blood-supply from the vessels coming from the 
skin, and that the circulation should be as abundant as pos- 
sible. This can be accomplished by loosening the skin of 
the anus in a different manner.' The method I suggest is 
somewhat different from that proposed by Mr. Ball or Dr. 
T. C. Martin, and consists (1) in doing away with the elliptical 
incisions which cut off the greater part of the circulation from 
the diseased area; and (2) in making six or eight linear 
incisions through the skin into the subcutaneous connective 
tissue. These linear incisions, beginning at a point outside 
of the point of irritation, follow the course of the radii of a 
circle whose centre is the anal canal. The skin-flaps lying 
between the adjacent radii are then undercut until the whole 
affected area is undermined and separated from the subcu- 
taneous tissue, thus dividing all nerve filaments. Should the 
dissection be difficult, and more room be needed, then every 
alternate flap could be loosened at the anal margin, and dis- 
sected outward toward the periphery. After all adhesions are 
loosened and the bleeding has been stopped, the parts are again 
replaced and sutured (Fig. 114). 



336 DISEASES OF ANUS, RECTUM, AND SIGMOID 

" The advantages of this operation over the original one 
of Ball lies mainly in the better nourishment of the flap. The 
blood must come from the circumference and must radiate 
toward the anal canal. In the original operation of Ball it 
enters only through the two pedicles of the skin attached to 
either extremity. In the operation that I propose the blood 
comes from the periphery — from the entire circumference of 




Fig. 114. — Showing Krouse's radial incisions, between which the skin and subcutaneous 
tissue is to be dissected from the underlying tissue. 

the flap. It is more direct in its course, it is closer to its source 
of supply, and its quantity is more abundant. The vitality 
of the flap is therefore better assured." 

The author has recently been convinced that the success 
following Sir Charles Ball's operation and its modifications 
has been due to the fact that in cutting loose the skin from 
the subcutaneous and submucous tissues the fistulous tracts 
are opened up and subsequent healing of the tracts follows. 
For the past year I have treated all such cases by finding, 



PRURITUS ANI 337 

opening up and tracing these sinuses to their internal openings. 
Recently I had one case in which there were four internal 
openings, all of which were opened up. They were very 
superficial, as they generally are, and did not involve the 
sphincter muscle. I dealt with them as ordinary fistulous 
tracts after the operation, making them heal from the bottom ; 
so far I have not had a single case where the procedure failed 
to relieve the pruritus ani. The following case will serve as 
illustration : 

Case. — W. B. presented himself for treatment for pruritus 
ani at St. Joseph's Hospital, September n, 1909. I found 
it to be the same case from which I had removed a number of 
hard papillomas August 3, 1908. Upon examination it was 
found there had been no return of the papillomas, but there 
was a thickened fold of skin across the posterior commissure, 
and above the skin scar tissue which extended up to the upper 
border of the internal sphincter, directly beyond which I found 
an opening to a blind sinus, which ran downward and out- 
ward to the external anal margin, where it bifurcated and a 
fistulous tract ran on each side, just beneath the skin nearly to 
the anterior commissure. These tracts were opened up and left 
to heal by granulation. So far as I have been able to learn, 
the patieat has been entirely relieved of the pruritus ani. I am 
convinced now that the hard papillomas removed from this 
patient a year previous were caused by the irritating dis- 
charge from these blind sinuses. 

X-ray and High-frequency Current. — Within the last few 
years these measures have been used with varying degrees of 
success, but on the whole results have not been sufficiently 
encouraging to warrant more than a trial in those cases that 
have resisted other forms of local treatment before subjecting 
them to operative measures. 



CHAPTER XIV 
COLOSTOMY 

Colostomy. — The formation of an artificial anus by an 
opening into the colon. — Gould. This definition is applicable 
to any portion of the colon and is intended to be applied to a 
permanent opening for the purpose of diverting the fecal 
current, whereas the term colotomy, which for the last two 
centuries was applied to this operation, means only a temporary 
opening into the colon for any purpose (the removal of foreign 
bodies, etc.), after which the colon is immediately closed. 

Colostomy is, therefore, applied to any form of opening 
into the colon that is to be used for the purpose of an artificial 
anus, whether temporary or permanent. 

Temporary colostomy is now employed very frequently in 
the treatment of various diseased conditions of the rectum, 
sigmoid, and colon, as a preliminary operation to extirpation 
or resection of the lower end of the intestinal tract, in imper- 
forate ani, in complicated fistulse between the intestine and 
urinary organs, in certain types of prolapse, and in strictures 
of the sigmoid and rectum. 

Permanent colostomy is employed in inoperable strictures 
and in neoplasms of the lower part of the intestinal tract, in 
cases in which it is impossible to re-establish the continuity of 
the intestinal tract after resection of the diseased portion, or 
where the sphincters and entire anus have been removed in 
amputating the rectum for malignant disease. 

Since surgeons have made such frequent use of colostomy 
for temporary purposes they have modified the former technic 
with special reference to closing the artificial anus readily and 
without having to resect the bowel or even to enter the peri- 
toneal cavity. 



COLOSTOMY 339 

The operation of the present day is confined almost entirely 
to the abdominal route. Lumbar colostomy has been aban- 
doned almost entirely, except in those cases where the disease 
involves the descending colon, or where there is an abnor- 
mally short mesocolon, or where the descending colon is so 
bound down by adhesions as to make it impossible to draw it 
out through the abdominal wound, and even in such cases the 
majority of surgeons would prefer tapping the transverse colon 
from in front. 

With the modern technic properly carried out, the mor- 
tality from this operation by the abdominal route is practically 
nil, except in those cases of complete obstruction of the bowel 
and where operation has been too long delayed. 

Lumbar colostomy having now become obsolete, its technic 
is not here given, but I refer the reader to previous works on 
diseases of the rectum and anus. 

There are certain general directions or rules to be fol- 
lowed in the selection of the locality at which the colon should 
be opened. There are three localities from one of which the 
selection is generally made, (i) the left inguinal, (2) the 
transverse, and (3) the right inguinal. The selection of one 
of these three depends upon the location of the disease. The 
opening should be sufficiently far above the disease not to 
be involved by it. Conversely, however, the artificial anus 
should not be placed farther above the diseased portion of the 
bowel than is absolutely necessary, because the farther above 
the normal anus the more fluid the stools, and the more fluid 
the stools the more likely the patient is to be annoyed by fecal 
incontinence. 

Left Inguinal Colostomy. — Left inguinal colostomy con- 
sists in opening the abdomen in the left inguinal region, pull- 
ing a portion of the sigmoid or descending colon out through 
this opening, suturing it to the side of the wound, and opening 
it. This may be made either a permanent or a temporary 
opening. 



340 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Permanent Left Inguinal Colostomy. — This is the 
most common form of an artificial anus, and when, therefore, 
the term colostomy is used without qualification, the perma- 
nent variety is implied. It is just possible, however, that the 
disease for which the permanent colostomy is performed may 
so unexpectedly improve under the new conditions that the 
artificial anus may be closed ; such a possibility, therefore, 
should always be borne in mind, and such measures taken in 
performing the operation as will enable the operator to close 
the artificial anus, without doing a resection or opening up 
the peritoneal cavity. Even though the artificial anus has been 
used for several years, the sigmoid and rectum below the open- 
ing do not become atrophied, as was once supposed. 

Technic. — Let the abdomen of the patient be prepared as 
for any other abdominal operation. He is placed flat upon his 
back on the table, and a general anaesthetic administered unless 
contraindicated, when it may be done under a local anaesthetic 
(as hypodermic injections of a weak solution of cocain, 1 / 10 
of i per cent.). 

An incision from two to three inches long is made, about 
two inches to the inner side of the left anterior superior spine 
of the ilium and one inch above it ; and this incision should 
cut at right angles an imaginary line drawn from the left 
anterior superior spine of the ilium to the umbilicus (Fig. 115). 
With one stroke the incision is carried through the skin and 
subcutaneous fat down to the fascia that separates it from the 
muscle. The fibres of the muscle must be separated and not 
cut, each in the order in which they are exposed, the external 
oblique, whose fibres run downward and inward, the internal 
oblique, whose fibres run downward and outward, and then 
the transz'crsalis abdominis, which takes a transverse direc- 
tion. After separating the fibres of the latter, the transversalis 
fascia is exposed and split. The incision is now carried 
through the subserous areolar tissue to the peritonaeum. The 
muscle-fibres are held apart by retractors, as each layer is 
separated. Spurting vessels are ligated, all oozing is stopped 



COLOSTOMY 



341 



by hot gauze compresses and the wound made perfectly clean 
before opening the peritonaeum. The patient's position should 
now be changed from that of prone to that of the Trendelen- 
burg posture. This will cause the small intestine and omentum 




falter ft. Gale >9*o, 

Fig. 115. — Inguinal colostomy — first step. Diagram locating surface openings. 

to gravitate to the upper part of the abdominal cavity. The 
peritonaeum is divided between two forceps, after which the 
incision is enlarged, using the finger as a guard to protect the 
intestines beneath. The index finger may now be introduced 



34,2 DISEASES OF ANUS, RECTUM, AND SIGMOID 

through this opening toward the median line, carrying it down 
until it touches the vertebra, when it is swept outward and 
upward until it is brought to the surface, which will generally 
bring with it the descending colon, this being readily recog- 
nized by its size, the longitudinal muscular bands, the saccula- 
tions and appendices epiploicse. Should there be any difficulty 
in hooking up the descending colon with the bent index finger, 
it may be inflated with gas through the rectum, or, should 
this fail, the incision may be enlarged sufficiently to introduce 
the whole hand in order to trace the bowel down from above, 
or up from the pelvis. If the small intestines or omentum 
should protrude from the abdominal wound, they may be held 
in place by a large pad of gauze. When the loop of the sig- 
moid is brought out through the wound, it should be examined 
thoroughly to see if it is involved in the disease, and in order 
to note especially the length of the mesocolon, which has to 
be of normal length in order to carry out the following sug- 
gestions for permanent colostomy. 

To be able to obtain a certain amount of sphincteric con- 
trol over the discharges from the bowel, it has been recom- 
mended by Tuttle to pull down the lower fibres of the external 
oblique and afterward the fibres of the internal oblique 
laterally for three-quarters of an inch (Fig. 116). The skin is 
separated from the external oblique downward for about two 
inches, where an opening is made through the skin, just above 
Poupart's ligament, large enough to pull through it the loop 
of the sigmoid. The loop of the sigmoid is now drawn out 
through the first incision for two or three inches, and a tape 
passed through a slit in the mesocolon beneath the centre of 
the loop, the ends of the tape are brought round the bowel, 
are left long and clamped with catch-forceps. A pair of long 
dressing-forceps are passed through the second opening in the 
skin through the canal between the skin and external oblique 
muscle; then through the fibres of the latter and the slit 
between the internal oblique fibres. The ends of the tape 
which are around the bowel must be caught, pulled through 



COLOSTOMY 



343 



the canal and out through the second opening in the skin, the 
loop of the sigmoid being made to follow it, using due care that 
the bowel is- not injured by the traction (Fig. 1 17). A glass or 
hard-rubber rod about six inches long is now passed through 
the opening in the mesentery made for the tape for the purpose 
of making an acute spur and for holding the loop of the sig- 




FlG. 116. — Inguinal colostomy — second step, showing the fibres of the external and internal 
oblique muscles drawn down and stitched. 

moid in that position. The first abdominal wound is now closed, 
cat-gut sutures being used for the deeper layers and silkworm- 
gut for the subcutaneous sutures. The wound is sealed with 
collodium and dressed with sterile gauze, over which a layer 
of protective tissue is placed, and sealed to the skin with chlo- 
roform in order to protect it from infection when the bowel 
is opened at the lower incision. The protruding loop of the 



31-t DISEASES OF ANUS, RECTUM, AND SIGMOID 

bowel is left unopened from twenty-four to forty-eight hours, 
unless an emergency requires it to be opened sooner. It is 
also covered with rubber protective in order to prevent the 
gauze from adhering to its serous coat, after which the gauze 
dressing is applied, and kept in place by an abdominal binder 
or adhesive strips. The bowel is opened at the time decided 
upon by a simple incision in the line of the longitudinal fibres 




Fig. ii7- — Inguinal colostomy — third step. 

of the bowel. After two or three weeks the protruding por- 
tions of the bowel around this incision should be trimmed 
down flush with the surrounding skin. The bowel may be 
cut across, leaving the two ends protruding as in Fig. 118. 
In the majority of cases the patient will soon gain control over 
his fecal discharges through the sphincteric action of the exter- 
nal and internal oblique muscles, but if these should fail then 
a truss with a compress may be applied between the protruding 
end of the bowel and the first incision, which will give the 



COLOSTOMY 34,5 

patient almost perfect control. It will be found that the posi- 
tion of this opening is most convenient for the personal super- 
vision of the patient. A combination compress and a small 
receiver for the discharges from the bowel has been devised 
by the Charles Willms Surgical Instrument Company, Balti- 
more, Maryland, which the author has found to be very ser- 
viceable (Fig. 119). 




Fig. 118. — Inguinal colostomy — completed. 

Temporary Colostomy. — The method employed for a 
temporary colostomy is exactly similar to the one just described 
for permanent colostomy, to the point of drawing out the loop 
of the sigmoid through the first incision. The loop of the 
bowel is to be drawn taut from above downward and suffi- 
ciently out of the incision to allow a glass or hard-rubber rod, 
from six to eight inches long, one-fourth inch thick, to be 



346 DISEASES OF ANUS, RECTUM, AND SIGMOID 

passed through the mesentery beneath the loop of the colon, 
this for the purpose of making a sharp spur, and for holding 
the bowel in this position. If the abdominal incision is found 
to be unnecessarily long, the ends can be drawn together with 
cat-gut sutures, leaving only sufficient room for the protrusion 
of the bowel. The bowel is now covered with rubber pro- 
tective, then with gauze, which is held in position by adhesive 
strips, and the bowel left unopened as previously recommended 
for permanent colostomy. 

When the time for opening the bowel has arrived the 
incision for a temporary colostomy is begun at the upper 
angle of the wound in the abdominal wall, and is carried 
downward, following the longitudinal fibres of the bowel to 




Fig. 119. — Compress and receiver for inguinal colostomy. 

a point just beyond the rod that has been passed through the 
mesentery. A transverse incision is now made, covering about 
two-thirds of the circumference of the bowel, which cuts the 
longitudinal incision at right angles, forming a T-shaped 
incision. In this instance the flaps of the bowel are rolled back 
on either side, but not trimmed off, so that they may be 
utilized subsequently when closing the artificial anus. 

Let the patient be confined to the recumbent posture for 
ten days or two weeks, and the diet for the first few days 
should be soft or liquid until the bowel is opened. For the 
first few hours it may be necessary to give an opiate to allay 
pain, but avoid this if possible, as it tends to increase the 
amount of gas in the bowel, which is likely to be annoying 
until the bowel is opened. 



COLOSTOMY 



347 



The rod should be kept under the bowel for at least two 
weeks, and the ends of it wrapped with strips of gauze to 
prevent irritating the abdominal wall. I decidedly prefer the 
rod to the suture of carbolized silk as recommended by Ailing- 
ham, because the former does not allow any sagging and keeps 
a sharp spur. 

In case of an alarming distention of the bowel by gas or 
fecal accumulation making it necessary to open the bowel at 
once, this may be done by first putting a circular purse-string 
suture around the portion to be opened. Then, by using a loop 
of the purse-string suture on one side and the two ends of it 
on the other to raise that portion of the bowel up, a crucial 




Fig. i 20. — Paul's intestinal tubes. 



incision is made in the bowel within the radius of the purse- 
string suture. A Paul tube (Fig. 120), which has a double 
flange at the end to be introduced, is now introduced into the 
opening of the bowel, and the purse-string suture is drawn 
around it between the flanges; a long rubber drainage-tube 
is attached to the distal end of the tube, and the fecal matter 
is thus drained off into a vessel provided for the purpose. As 
Gant has pointed out, the opening of the bowel before adhe- 
sions have formed should only be done in extreme cases, as he 
has found the mortality to be much higher than when it is 
opened from thirty-six to forty-eight hours afterward. 

In either the permanent or temporary method of operating 
for colostomy, the lower segment of the bowel can be readily 



348 DISEASES OF ANUS, RECTUM, AND SIGMOID 

irrigated whenever necessary, a very important procedure, in 
order to wash out any pus, fecal matter or debris likely to 
accumulate there. 

If the disease for which colostomy is done is in the upper 
end of the sigmoid, open the bowel higher up in any part of 
the descending or transverse colon, but the previous injunction 
should always be borne in mind, never to make the opening 
higher than is absolutely necessary. 

In cases of disease involving the transverse or upper por- 
tion of the ascending colon, where it becomes necessary to 
open the caecum in order to give relief, it is better, if the case 
is malignant and operable, to resect the diseased portion of the 
bowel, or in inoperable cases to do an anastomosis between 
the healthy bowel above the growth, and a similar portion 
below it. In cases of ulceration or intractable inflammation 
of the colon, it is better to do an appendicostomy or a caecos- 
tomy, as described in the chapter on ulceration. These recom- 
mendations are made in preference to right inguinal colostomy, 
on account of the fluid condition of the faeces in this locality. 

Closure of a Temporary Artificial Anus. — The 
method of closing an artificial anus will depend upon the 
manner in which it has been made. If the spur made is very 
acute, as shown by the fact that no fecal matter has ever 
passed over it into the lower segment of the bowel, the spur 
must first be cut through by clamping it with straight hysterec- 
tomy or long-clamp forceps, one blade of which is introduced 
into the upper and the other into the lower segment of the 
bowel. They are gradually tightened each clay, until they cut 
their way through by pressure necrosis of the tissues. It 
requires from five to six days to do it, and it is very painful. 
After this, the fecal matter will readily pass down the lower 
segment of the bowel, and the artificial anus may close spon- 
taneously. Should this not occur, the flaps of the bowel which 
were rolled back when the bowel was opened must be dis- 
sected loose, unrolled, put back in place, and stitched together 
with a double row of sutures, one through the mucous mem- 



COLOSTOMY 349 

brane and the other through the serous layer, or as much of 
it together with the muscular layer as can be got, and the 
ends of the flaps stitched to the lower segment of the bowel, 
from which they were severed when the transverse incision 
was made, the edges of the flaps and the lower segment having 
first been freshened. The skin around the abdominal wound 
is to be freshened, and the abdominal wall dissected loose from 
the intestine for about one inch beneath the wall all around 
the wound, then the edges are brought together with silkworm- 
gut sutures. This method may give very satisfactory and 
successful results. 

A second one consists in dissecting the bowel loose from 
its attachment to the abdominal walls, resecting both ends of 
the bowel that have protruded beyond the abdominal opening, 
and doing an end-to-end anastomosis, either by the aid of a 
Murphy button or by the Halstead method. I did this opera- 
tion successfully some years ago, but found the walls of the 
bowel very much thickened and extensive adhesions which 
made the operation very difficult. I therefore advise the use 
of the first method if it can be done successfully. 



CHAPTER XV 

PATHOLOGICAL GROWTHS, OR TUMORS OF THE ANUS, 
RECTUM, AND SIGMOID 

" For practical purposes, a tumor may be defined as a 
persistent mass of redundant new formation, not obviously 
due to any extrinsic cause, which grows independently of the 
body, with which it is structurally and functionally uncom- 
bined; so that, although it generally assumes a more or less 
circumscribed form, it is nevertheless distinct from any known 
anomaly. 

" Tumors grow and are nourished like normal parts of 
the body, yet in return for the nutriment thus supplied they 
contribute to it nothing useful ; indeed, their relation to the 
rest of the organism differs but little from that of parasitism. 

" Tumors may be classified on many bases — physiological, 
morphological, chemical, genetical, etiological, etc. ; but by far 
the oldest and most generally useful classification is that which 
divides them, according to their physiological properties, into 
the malignant and non-malignant or benign, and for our imme- 
diate purpose this will suffice. Here, however, it must be 
noted that tumors exhibit many degrees of malignancy, both 
in the plus and minus directions." (W. Roger Williams, 
" Natural History of Cancer," page 3.) 

Malignant Tumors, — These exhibit the following charac- 
teristics : (1) They infiltrate the surrounding tissues; (2) 
infect adjacent lymph glands; (3) tend to recur after removal; 
(4) become disseminated in distant organs; and (5). inev- 
itably destroy life. 

Innocent Tumors. — These are, as a rule : ( 1 ) encapsulated 
and, when diffuse, do not infiltrate; (2) do not infect the 
lymph glands; (3) nor recur after complete removal; (4) do 
not disseminate; and (5) only imperil life when they grow in 
the vicinity of vital organs. 

350 



PATHOLOGICAL GROWTHS 351 

There are two genera of tumors to which the adjective 
malignant is especially applicable — sarcomata and carcino- 
mata. 

It is important to bear in mind that innocent tumors may, 
and often do, destroy life. The essential difference between 
an innocent and a malignant tumor may be expressed thus: 
The baneful effects of innocent tumors depend entirely on 
their environment, but malignant tumors destroy life what- 
ever their situation. (J. Bland-Sutton, " Tumors, Innocent 
and Malignant," page 2.) 

The question of the origin of malignant from non-malig- 
nant tumors involves important practical issues, especially 
the proclivity of non-malignant tumors to become malignant. 
If any such tendency really exists, then non-malignant tumors 
ought to be promptly extirpated. 

Prior to the application of the microscope to new growths, 
it was generally believed that every chronic tumor (" scir- 
rhous") either was malignant or tended to become so. 

The difficulty then of discriminating between malignant 
and non-malignant tumor-like swellings rendered some such 
belief inevitable ; but since the utilization of the microscope 
it is surprising to find the old creed still so influential. 

Now, in the light of modern research is this belief justi- 
fiable? 

Since innocent tumors may inflame, suppurate, ulcerate, 
necrose, and degenerate, just like physiological parts of the 
body, it seems not unreasonable to suppose on a priori grounds 
that they may also become the seat of malignant disease. The 
. occasional coexistence in the same organ of benign and malig- 
nant tumors favors this view. Such are the chief considera- 
tions which have given rise to the common belief that innocent 
tumors are peculiarly apt to become malignant. 

On critical examination of the subject, two considerations 
( have much impressed me. 

First, the rarity with which these two kinds of neoplasms 
coexist in the same organ ; so that, even admitting that malig- 



352 DISEASES OF ANUS, RECTUM, AND SIGMOID 

nant transformation to take place in all such associated neo- 
plasms, the event must be one of great rarity — very much 
rarer than it would be if non-malignant tumors were espe- 
cially prone to become malignant. 

Secondly, the inconclusiveness of the evidence as to malig- 
nant growths in most of these cases having sprung from their 
non-malignant associates. In many instances, it is perfectly 
evident that the association is a mere coincidence, each neo- 
plasm having originated independently. In others the coexist- 
ing neoplasms are more closely associated ; but, even in these, 
the appearance of the non-malignant tumors is often such as 
hardly to countenance a belief that the malignant disease had 
sprung from them. 

In short, thorough examination of the subject in all its 
bearings has convinced me that non-malignant tumors have no 
special proclivity to malignancy. 

The possibility of benign tumors subsequently developing 
malignant characters has been thoroughly proved; but this 
is a very different thing from admitting that such tumors are 
specially prone to malignancy. This is disproved by the 
extreme rarity of the coincidence. Non-malignant tumors are, 
in fact, less liable to originate malignant disease than are the 
normal morphological elements of the body itself. (W. Roger 
Williams, " Natural History of Cancer," page 288.) 

Adami, "Principles of Pathology," Vol. I, page 619: 
" It is the grade of vegetative power of the cells which deter- 
mines their malignancy, though, as we shall point out (pages 
628, 632), the malignancy of a given tumor in a given tissue 
of a given animal is the expression of the interaction between 
the cell malignancy and the resisting powers of that tissue 
toward the growth of that particular type of cell." 

On what peculiar characteristic the malignancy of tumors 
depends is not definitely known. The chief histological differ- 
ence between malignant and non-malignant is the atypical 
arrangement of their histological elements. 



PATHOLOGICAL GROWTHS 353 

" In normal growth no tissue, no matter how vigorous its 
growth, can overcome the resistance to its growth that a 
neighboring tissue offers. Epidermis, when implanted in the 
subcutaneous tissues under the most favorable conditions, will 
for a time have a limited growth, but soon atrophies and dis- 
appears. The same thing happens when pieces of periosteum 
are implanted in places Avhere periosteum does not normally 
exist. Experiments made with the inoculation of tumors 
show the same thing. Such inoculations have not only been 
made from man on the lower animals, but from animal to 
animal. In the most malignant tumors, where we know the 
effects produced on the bearer when particles of the tumor enter 
into the circulation, cells and juices from such tumors have 
with every precaution been injected into the circulation with 
negative results. A few positive results have indeed been 
claimed but their number is too few in view of the frequency 
with which such experiments have been made to lead us to 
have much confidence in them. Cohnheim assumes that the 
malignity of a tumor depends more upon the nature of the 
tissues of the bearer than upon any other moment. There 
must be a weakness, a want of resistance to the growth in the 
other tissues, to constitute malignity. This condition may 
be inherited or acquired. Age seems to be a predisposing 
moment, and Thiersch seeks in this want of resistance in the 
connective tissue, brought about by age, the cause of carcino- 
mas in the connective tissue not resisting the growth of the 
epidermis. According to Cohnheim the germ of a tumor may 
remain quiescent for years, nay, it may never come to develop- 
ment, because it cannot overcome the physiological resistance 
of the tissues; but when from any cause this resistance is 
lowered or taken away, then we have the tumor ; and a tumor 
is malignant just in the degree that this resistance is wanting. 
Inflammation may act in the same way by lowering the resist- 
ance, and if inflammation and traumas have any action in 
causing tumors it is most probably in this way." I \Y. T. 
23 



354 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Councilman, M.D., " Reference Handbook of the Medical 
Sciences," Vol. Ill, page 407.) 

The classification of tumors of the rectum here used is 
from an histological basis, and the one in general use : 

I. — Tumors derived from the connective-tissue group : 

Fibroma. — Composed of fibrous tissue. 

Myxoma. — Composed of well-formed isolated cells, of a 
somewhat stellate appearance, with a matrix containing a vary- 
ing amount of mucin. 

Lipoma. — Composed of fatty tissue. 

Enchondroma. — Composed of cartilage. 

Lymphoma. — Composed of cytogenic tissue, the type of 
which is found in the lymph glands or in the bone marrow. 

Angioma. — A tumor made up of blood-vessels. 

These tumors all conform strictly in their structure to their 
physiological types. 

II. — Now the group of sarcomas, which also come from 
the connective tissue but which are distinguished by the excess 
of cells over the formed material, thus conforming to the type 
of embryonic tissue : 

Sarcomas. — Spindle-cell Sarcoma, Round-cell Sarcoma, 
Alveolar Sarcoma, Melano-sarcoma, Chloroma. 

Papilloma. — A tumor whose chief constituents are epithe- 
lial cells, but which also contains vascular connective tissue, 
the whole being formed in accordance with physiological types. 
These types are the papilla of the skin and the villi of the intes- 
tine. According to their seat they are divided into the hard 
and soft papilloma. 

Adenoma. — One composed of glandular epithelium and 
vascular connective tissue, generally agreeing in the arrange- 
ment of its elements with some of the glandular structures of 
the body. 

Epithelial Carcinoma (Epithelioma). — A tumor 
composed of epithelium similar in character to the covering 
epithelium, but in the arrangement of its elements agreeing 
with no typical structure in the body. The cells are arranged 



PATHOLOGICAL GROWTHS 355 

in masses, which are separated from each other by vascular 
connective tissue. Neither the fibres of the connective tissue 
nor the blood-vessels penetrate the masses of cells. 

Glandular Carcinoma. — One having its origin in and 
principally composed of glandular epithelium, agreeing in its 
general structure with the epithelial carcinoma. 

Teratoma. — A tumor into whose structure a whole system 
of the body may enter, and which arises from parts where the 
tissues found in the tumor do not normally exist. The epi- 
dermic structures of the body are most often represented in 
these tumors (as in dermoid cysts). 

Of this classification the sarcomas of the connective-tissue 
type and the carcinomas of the epithelial type are regarded as 
malignant. 

Benign Tumors of the Rectum. — Under this heading I 
include all varieties of tumors before mentioned, except those 
described as malignant, viz., sarcomas and carcinomas. 

In inflammatory affections of the intestine, the mucosa and 
submucosa are not infrequently the seat of inflammatory and 
hyperplastic growths involving both the connective tissue 
and the epithelium. These are usually secondary to necrotic 
and inflammatory processes, some of them of an infective 
nature, though sometimes arising without any demonstrable 
cause. (Ziegler, page 676.) 

Most benign tumors found in the rectum are polypi and 
are found on mucous membrane. 

The term polypus is used very indiscriminately, being fre- 
quently applied to any pedunculated growth on the mucous 
membrane, of whatever histological character, and also to 
many that are sessile, pyriform, and pendulous neoplasms. 
Let this term be confined to pedunculated tumors from the 
mucous membrane of the bowel ; it does not imply the char- 
acter of its histological elements. 

While polypi may be found in any part of the intestinal 
canal, they are far more often found in the rectum. In chil- 
dren, they generally exist singly; in adults, they are more 



356 DISEASES OF ANUS, RECTUM, AND SIGMOID 

often multiple, and generally found just within the upper 
margin of the anus, or lower portion of the rectum (Fig. 121 ). 
Varying in size from that of a pea to a large walnut, or even 
to that of a small lemon in rare cases, they are of various 
histological types, as fibroma, adenoma, cystoma, and lipoma, 
the most common being the soft, mucoid variety, which prob- 
ably originates in an inflamed solitary follicle, the meshes of 
which are filled with a thick, viscid fluid, sometimes contain- 
ing true Lieberkuhn tubules. This variety is generally found 
in children. 



Fig. 121. — A polypus taken from a large hemorrhoid. 

The longer a polyp remains in the rectum (and as a rule 
the nearer it is situated to the grasp of the sphincter) the 
more elongated will be its pedicle. The pedicle is due to the 
elasticity and mobility of the tissues in which they develop, 
and to the peristaltic effort of the bowel to rid itself of the 
abnormal object. The pedicle is generally very narrow, but 
occasionally the tumor is attached by a broad band of mucous 
membrane. They are frequently passed outside of the anus 



PATHOLOGICAL GROWTHS 357 

during defecation, and are grasped by the sphincter. So long 
as they remain well up in the rectum, they do not produce any 
marked symptoms, but when they are located near the sensi- 
tive margin of the anal canal they produce a frequent desire 
to defecate, or a feeling of fulness. 

Polypi present different appearances according to their 
histological structures ; sometimes a raspberry-like growth 
with soft, velvety surface. The lipomatous polypus appears 
smooth, shiny, and lobulated ; sometimes it may be ulcerated 
on the surface. The fibroid polypus is spherical or ovoid in 
shape, covered with normal or bright red mucous membrane. 

Diagnosis.- — The diagnosis of a polypus is very simple. 
They are either seen protruding at the anal margin, can be 
felt by the finger, or can be seen through the proctoscope. 
When grasped between the fingers they may be soft and 
pliable, or firm and fibrous. 

Treatment. — This consists either in twisting them off, 
or ligating the pedicle and snipping off the tumor beyond the 
ligature, or clamping the pedicle with an angiotribe, cauter- 
izing it, and snipping off the tumor beyond the angiotribe. 
This latter method is best adapted to those attached by a broad 
mucous band. If not removed by the angiotribe, it is better 
to suture the edges of the broad band of attachment after the 
tumor has been cut off. No subsequent dressing will be neces- 
sary, but the rectum may be irrigated daily for one week with 
an antiseptic solution, which will also keep it clear of fecal 
matter. 

Fibroma. — True fibroma of the anus and rectum are very 
rare. They are composed of fibrous connective tissue of the 
submucosa, and sometimes grow to a considerable size. Solid 
or cavernous, mural or pedunculated, they are yet different 
from a fibrous polypus, for while in the latter there may be a 
considerable amount of fibrous tissue, it is mixed with glandu- 
lar and other elements. In a pure fibroma, the fibrous tissue is 
arranged in wavy bundles, and ordinarily contains very few 
blood-vessels. Sometimes the tumor contains more or less 



358 DISEASES OF ANUS, RECTUM, AND SIGMOID 

jelly-like mucus. When the fibroma remains in the intestinal 
wall, it is spherical or ovoid in shape ; is closely attached to 
the muscular coat, and the mucous membrane is movable over 
it. The symptoms are similar to those of mucous polypi. 

Myxoma. — The myxomata are tumors composed, in the 
main, of well-formed isolated cells of a somewhat stellate 
appearance, which are separated from each other by a matrix 
containing varying amounts of mucin. In this matrix there 
are large but thin-walled vessels. While this is their structure 
in the main, it is rare that we come across what may be termed 
a pure myxoma. In general, areas of the tumor show more 
condensed fibrous" tissue, or cartilaginous masses, or frequently 
lobules or collections of fat cells, while in other cases portions 
are of a sarcomatous type, and show close collections of 
spindle cells. Thus it is doubtful whether it should be regarded 
as a separate form of tumor, or rather a myxomatous modi- 
fication or a degeneration of some one of the other forms. 

These tumors, slow in growth, are soft and fluctuating, so 
as to give the impression, at times, of being cystic or fluid 
masses. They never form metastases, but, imperfectly re- 
moved, are liable to recur, while, again, a certain number 
take on sarcomatous properties and so may become malignant. 
In such cases, the metastases are not myxomatous, but wholly 
sarcomatous. 

The favorite seat of such tumors is the buttocks, between 
the glutsei muscles. They sometimes form multiple soft polypi. 

Lipoma. — Tumors composed of adipose tissue are found 
in the rectum, and also high up in the intestinal canal. They 
ordinarily develop in the submucous layer of the intestinal 
wall and are either closely attached to the rectal Avail, or 
assume a polypoid shape with a pedicle. They may grow to 
considerable size, sometimes so dragging upon the rectal Avail 
as to produce a prolapse of this organ. 

These tumors are essentially benign, of slow growth, and 
do not recur after complete extirpation. They vary in con- 
sistency, according to the amount of connective-tissue matrix, 



PATHOLOGICAL GROWTHS 359 

but ordinarily a true lipoma is soft and fluctuating. Rarely, 
portions of the tumor take on a sarcomatous development. 
These fatty tumors occasionally occur outside of the rectum, 
and yet are attached to its walls, which may obstruct its lumen 
by pressure. 

Treatment. — When pedunculated, the pedicle should 
always be ligated before the tumor is removed, owing to the 
possibility of peritoneal invagination into the pedicle. When 
situated in the rectal wall it should be removed by an incision 
of the mucous membrane, enucleated, and, if possible, the 
wound closed by sutures. 

Enchondroma. — This, one of the rarest tumors of the con- 
nective-tissue variety that occurs in the rectum, is composed 
of one or the other variety of cartilage, hyaline, fibrous, or 
reticulated (hyalo-enchondroma, fibro-enchondroma, reticu- 
lated enchondroma). They may be single or multiple, pos- 
sessing in general a well-marked fibrous capsule and are glob- 
ular or lobulated. 

Sometimes there may be glandular tissue combined with 
the cartilage, and these mixed tumors are liable to take on 
sarcomatous characters, and become malignant. They grow 
slowly, are firm in consistency, and generally benign in 
character. 

Lymphoma. — This type is occasionally found to develop 
from the lymphoid tissue, or solitary nodes, which exist in 
the rectum and through the large intestine. It is soft to the 
touch, and attains considerable size. As its definition implies, 
it is due to a hyperplasia of the lymphoid tissue. The tumors 
are slightly lobulated, always single, of a bright red color, and 
of a soft consistency. The symptoms produced by the tumors 
resemble those produced by polypi, and their treatment is 
similar to that for lipoma. 

Angioma.—" We cannot but conclude that the majority 
of so-called angiomas, or tumors having vessels as their main 
constituent, are spurious blastomas, whether formed of blood- 
vessels (' hcemangeiomas ') or of lymph vessels (' lymphan- 



360 DISEASES OF ANUS, RECTUM, AND SIGMOID 

giomas'); they possess no pozver of independent growth. 
Mere dilatation and filling of vessel spaces with fluid is not 
growth, even if preceded by aplasia and followed by atrophy of 
the tissue proper to the part. And in the majority of cases 
the evident increase in length of the vessels (such as must 
occur in cirsoid aneurisms) or thickening of the walls of the 
individual dilated loops {such as we see in cavernomas) is 
apparently not in excess of the physiological requirements. 
We find, that is, no evidence of proliferative capacity, at most 
a widening of pre-existing vessels, either of congenital origin 
and ascribable to a primary want of co-ordination in the growth 
of the vessels of a part and of the tissue or cells they should 
nourish, or of postnatal origin, due to alteration in blood 
pressure or the nature of local venous obstruction, as, for 
instance, in the multiple capillary telangiectases, which can be 
produced in the liver by partial obstruction and stenosis of 
the hepatic veins (hemorrhoids are of this nature), or due to 
local atrophy of the cells of a restricted area in an organ, 
the capillaries undergoing what we may speak of as compen- 
satory dilatation. 

" Independent growth is the test of what constitutes a 
tumor of this order. With this construction of the term true 
angiomas are very rare in the rectum." (Adami, " Principles 
of Pathology," Vol. I, page 748.) 

Tuttle only collected the reports of two such cases. Adler 
reported one, at the meeting of the American Proctologic 
Society, June, 1909, which report with the illustrations I give. 

Angiomas are derived from the submucosa and are usually 
congenital. The diagnosis is readily made by the tortuous 
blood-vessels of the parts affected, and the infiltration of the 
affected tissues. 

Report of a case of nevus simplex of the anus and lower 
portion of the rectum by Lewis H. Adler, Jr., of Philadelphia, 
(Transactions of the American Proctologic Society, Vol. II, 
page 168) : 



PATHOLOGICAL GROWTHS 361 

Case. — Male, aged forty, was seen March 24, 1909; the 
condition congenital. Symptoms : an external fulness at the 
anal margin, which was increased in walking or at stool ; there 
was a prolapse of several tumors, supposedly hemorrhoidal, 
while at stool; there was frequent bleeding when the bowels 
were evacuated, and there was difficulty in having a stool on 
account of the blocking of the canal, by the increased fulness 
of the parts, both internal and external. 






• ■ mm 





Fig. 122. — Nevus simplex. 

Twenty years previously the internal hemorrhoids had 
been removed under ether anaesthesia, which gave him con- 
siderable relief for several years. The examination just prior 
to the operation revealed a mass of thickened skin about two 
inches in width, of a dull purplish hue, surrounding the anus 
with an elevation of about one-sixteenth of an inch ; there were 
numerous hairs scattered over this area. When made to bear 
down, the hemorrhoidal masses protrude and the external por- 
tion is visibly increased. (The accompanying photograph was 
taken before the operation. Fig. 122.) 



362 DISEASES OF ANUS, RECTUM, AND SIGMOID 

The patient was operated on March 29, 1909. He died 
a few hours after operation, from symptoms indicating cardiac 
embolism. 

In excuse for reporting this case under the head of 
angioma, the pathological findings showed a moderate hyper- 
plasia of the walls of the blood-vessels, which were surrounded 
with dense fibrous tissue. The skin covering the nevus was 
also thickened. 

The two groups — sarcomas and epithelial carcinomas — 
will be described under Malignant Tumors. 

Papilloma. — A papilloma is any growth on the skin or 
mucous membrane based upon or resembling a normal papilla. 
These stand midway between true tumors and inflammatory 
growths and are divided into two general groups, hard and 
soft. 

A hard papilloma, a form in which the connective-tissue 
framework is denser and the cells fewer than usual. It grows 
chiefly from the skin. 

A soft papilloma, one growing from the mucous membrane, 
especially in the uterus, rectum, and bladder. (Gould.) 

Etiology. — Papillomas are generally due to a special irri- 
tation of the skin or mucous surfaces. 

Hard Papilloma. — Of these growths found in and around 
the anal margin, and on the neighboring parts, may be men- 
tioned, warts, and condyloma acuminatum. 

Warts. — " In these we deal with overgrowth of a collec- 
tion of papillae of the corium, covered by a common, thickened, 
and somewhat hypertrophied epiderm. They would seem to 
arise from irritation, are commonest in childhood, and have 
a marked tendency to disappear eventually. Some ascribe to 
them a definite infective origin, and clear evidence has been 
brought forward of their transmissibility." (Adami.) 

The author has seen several cases of warts appearing 
around the anus on the perineum, labia, and buttocks ; from 
one of these cases he removed some thirty or forty. Most of 
these were pigmented, and many of these either returned or 



PATHOLOGICAL GROWTHS 363 

others formed in their stead. The fact that they sometimes 
return need not deter the surgeon from removing them. Their 
return may be obviated, in a measure, by touching their bases 
with pure carbolic acid, after removal. 

Condyloma Acuminatum. — Long-continued irritation 
affecting any portion of the skin sometimes induces local 
hypertrophy of the papillae, which increase in length and 
often become subdivided or branched. The cutaneous 
growth thus produced might be an inflammatory fibrous 
papilloma (Fig. 124). It is usually described as a venereal 
wart or cauliflower excrescence (condyloma acuminatum), 
although it will be shown not to be due to a specific organ- 
ism. The special chronic irritation which induces it is that 
due to discharges from gonorrhoea! inflammation, chancrous 
pus, and decomposed preputial or vaginal secretions. The 
following case (Fig. 123) is a good illustration: 

Case. — W. B. presented himself at St. Joseph's Hospital, 
August 3, 1909, with hard papillomas around the anal margin, 
extending laterally from one to two inches on the skin surface 
and from two to three inches above the anterior commissure 
on the perineum. Under the influence of ether anaesthesia I 
removed these growths with scissors, subsequently finding a 
blind sinus at the posterior commissure in the upper part of 
the anal canal which was the source of the irritation that 
caused the papillomas. The patient made a good recovery. 

The papillomas are found around the anal margin, on the 
perineum and genitals, especially where opposite surfaces of 
the skin are in constant contact. They are firm in texture, 
usually whitish in tint, and may grow as large as an apple. 
They resemble in appearance the head of a cauliflower. The 
papillae as they grow tend more and more to subdivide ; they 
are composed of vascular fibrous tissue, they enclose a number 
of leucocytes, and their base is always infiltrated. 

The epidermis overlying the hyperplastic papillae is thick- 
ened. This form of papilloma is transmissible even more so 
than are the warts. (Ziegler.) 



364 DISEASES OF ANUS, RECTUM, AND SIGMOID 



The nature of the contagium in these cases is still a mooted 
question ; but there are reasons for believing, whatever it is, 
that it centres in the epidermoidal cells. (W. Roger 
Williams.) 



Wtk 



s ~£ 




Fig. 123. — Condyloma acuminatum. 



Soft Papilloma. — These, growing from mucous mem- 
branes, in general afford the most satisfactory examples of 
the form of tumor which develops in direct continuity with, and 
clearly from, a normal epithelial membrane. 



PATHOLOGICAL GROWTHS 



365 



The direct cause of the excessive growth of the cells in 
this particular locality is not easy to determine. Sometimes 
there is a history of a previous intestinal inflammation or 
ulceration, but that does not explain why it should result in 




Fig. 124. — Inflammatory fibrous papilloma. 




Fig. 125. — Finger-like papillomatous outgrowths, a, showing framework; b, showing the 
intervening cell. 

these overgrowths in some individuals and not in others. 
They assume various forms, a simple nodular tumor, pedun- 
culated and sessile, or masses of long fimbriated processes, 
resembling the fringe of an upholstered chair (Fig. 125, 
Adami), sometimes spoken of as villous tumors. 



366 DISEASES OF ANUS, BECTUM, AND SIGMOID 

Such growths may show themselves on any part of the 
mucous membrane of the rectum or sigmoid. I have seen two 
cases of the fringe-like masses encircling the lower margin 
of the rectum, but was unable to get a photograph of them, 
and when the mass was extruded, as it always was, during 
the act of defecation, it hung as a fringe around the anal 
margin. They were satisfactorily removed by first passing 
a mattress suture through their base, and making it continuous 
around the entire anal margin. These tumors show a frame- 
work of connective tissue, which follows faithfully the branch- 
ing of the growth, and is distinctly vascular. The outside of 
this is the epithelial layer. They may show abundant goblet- 
cells. 

Adenoma. — As adenomas in general are composed of 
typical glandular epithelium, corresponding to the mother 
tissue in which they are found, those in the rectum and large 
intestine agree in character with its glandular elements. The 
most typical adenomas show a well-marked basement mem- 
brane, between the cell layer and the underlying stroma ; where 
the growth is rapid and atypical this may be absent. While 
gland cells and stroma are essential to one another, the former 
are the dominant agents; the growth of the stroma follows 
that of the epithelium. 

I only mention here adenomas proper and adenomatosis, 
the latter of which is generally multiple. The following state- 
ments are true for all : When completely removed there is no 
recurrence ; they do not infect neighboring lymph glands, nor 
give rise to secondary deposits. When an adenoma causes 
death, it is in consequence of mechanical complications, 
depending on the situation and size of the tumor. (J. Bland- 
Sutton. ) 

Adenoma Proper. — An adenoma is a tumor constructed 
upon the type of and growing in connection with a secreting 
gland and must all be regarded as originating from cell nests. 
They are single or multiple, but much less numerous than 
where adenomatosis exists. In size varying from a small 






PATHOLOGICAL GROWTHS 367 

cherry to that of a hen's egg, some cases have been re- 
ported weighing as much as four pounds. They are gener- 
ally pedunculated and polypoid in shape (Fig. 126). A 
true adenoma of the rectum is very rare, as compared to 
adenocarcinoma of the same. The symptoms are identical with 
those of polypi, except that they bleed more freely. The 
treatment of simple adenoma is very simple. They may be 
twisted, tied, crushed, or destroyed by an angiotribe. 




Fig. 126. — Rectal adenoma. 

Adenomatosis. — In this condition portions of the glandu- 
lar tissue or surface become the seat of exuberant irregular 
adenomatous overgrowth, with evident functional disturbance. 
No sharp line of demarcation can be drawn between this and 
the preceding class. Under this heading come the multiple 
adenomatous polyps of the alimentary canal. (Adami.) 

The symptoms, course, and pathology of this condition 
differ in many respects from those of simple adenomas. " It 
is frequently supposed that multiple adenomata originate in 
the simple type ; there is no case reported, however, in which 
a single or simple adenoma recognized in childhood has ever 



368 DISEASES OF ANUS, RECTUM, AND SIGMOID 

developed into the multiple variety in after years." (Tuttle.) 
In cases of multiple adenoma a number of neoplasms sim- 
ilar in size and stage of development are observed from the 
beginning of the symptoms, as though they had originated at 
the same time, from the same cause. 

The exact cause of adenoma is not definitely known. Mul- 
tiple adenomas vary in size, form, and appearance. They may 




Fig. 127. — Multiple adenoma. 

be smooth, round and shiny or rough and wart-like, resembling 
a raspberry (Fig. 127). Sometimes spherical or elongated, 
their size may vary from a small pea to that of a hazel-nut, 
or larger. The tumors may be either hard or soft, according 
to the amount of connective-tissue stroma they contain and 
the extent of degeneration which has taken place. They are 
pedunculated, although the very small tumors may be sessile. 
Generally there exists a proctitis or colitis with multiple 



PATHOLOGICAL GROWTHS 369 

adenoma, generally supposed to be due to trophic changes in 
the mucous membrane of the large intestine and to infiltration 
of the connective tissue ; but is not caused by the irritation of 
the mucous membrane by the adenomas. 

Sir Charles Ball in his work " The Rectum," page 216, 
says that Dr. Bellela of Alexandria (Progres. Med., No. 30, 
1885) noted the occurrence of adenomata of the rectum caused 
by the deposit of the ova of Bilharzia haematobia in the mucous 
membrane. 

Symptoms. — These are diarrhoea, discharges of mucus 
and blood, pain, exhaustion, anaemia, and general debility, and 
when the tumors are large in size the passage of fecal matter 
is obstructed. 

Diagnosis. — -This is readily made by the subjective symp- 
toms together with a digital and proctoscopic examination. 

Here is a typical case of multiple adenomata reported by 
Dr. George B. Evans, of Dayton, Ohio: Mr. H., aged forty- 
four, plasterer, married, was admitted to St. Elizabeth's Hos- 
pital July 29, 1903. Proctoscopic examination revealed eight 
adenomatas, two inches above the internal sphincter. Two of 
these were much harder than the others and were evidently 
fibro-adenomatas. Upon introducing the protoscope farther 
up the rectum a large mass of small gelatinous polypi came 
into view. Two days later under a general anaesthetic Dr. 
Evans operated and removed the mass of polypi with a sharp 
curette, being unable to use the ligature or snare on account 
of excessive hemorrhage. The hemorrhage following curett- 
ing was controlled by packing with gauze wrung out of hot 
water. The patient made an uneventful recovery. A patho- 
logical examination of several of these polypi, especially the 
fibro-adenomatas, indicated them to be benign in character. 
Notwithstanding, by November of the same year, malignancy 
had developed at the seat of the fibro-adenomatas, and the 
patient refusing further surgical interference, died February 
26, 1904. 
24 



370 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Malignant Transformation. — It seems to be generally 
recognized that there is a strong tendency for multiple adenoma 
to become malignant. This tendency often manifests itself 
by the simple and malignant type existing in the same patient 
side by side, and occasionally even in the same tumor. Wulff 
states that only the multiple variety of adenoma show this 
tendency to malignant transformation. Tuttle also states that 
this agrees entirely with his experience, and further says: 
" There are no authenticated cases on record where a single 
pedunculated adenoid polypus has recurred in the form of a 
carcinoma." 

This predisposition to malignant transformation of mul- 
tiple adenoids, together with the exhausting rectal symptoms . 
before enumerated, makes this type of adenoma very danger- 
ous. So frequently scattered throughout the course of the 
large bowel, their entire eradication or palliation of their con- 
comitant symptoms becomes equally difficult and the progno- 
sis in all such cases is very grave. 

Treatment. — Medicinal treatment by mouth and by irri- 
gation affords only very temporary relief, and should never 
be relied upon as a curative measure; it only entails loss of 
valuable time. 

It is very important at the earliest opportunity to ascertain 
whether or not any of the adenoma have undergone malignant 
degeneration. This can be done by removing and examining 
several of them. If any indication of malignancy is shown, 
nothing short of an excision of the affected area should be 
undertaken. When not malignant, excise them through a 
proctoscope from the anal orifice, as high up the bowel as they 
can be reached. This can be done by twisting them off with 
long forceps, or by ligature, but far better by Lynch's Electric 
Angiotribe, worked through a large-size proctoscope. Thor- 
oughly and completely to do this requires repeated sittings, and 
let treatment be continued as long as any adenoma show them- 
selves. 



PATHOLOGICAL GROWTHS 371 

Where they have undergone malignant degeneration, it 
seems to be the consensus of opinion that the only thing to 
give permanent relief is to excise the entire affected area of 
the bowel. 

Colostomy and caecostomy have been done for diverting 
the fecal current and for the purpose of more thorough irri- 
gation, but have almost invariably failed in giving permanent 
relief. Caecostomy and appendicostomy combined with anas- 
tomosis between the ileum and the lower portion of the sig- 
moid colon, as done by Lilienthal, Rotter and Holtman, has 
given better results, but in Lilienthal's case it was found neces- 
sary to excise the entire large bowel between the points of 
anastomosis of the ileum with the lower portion of the sigmoid, 
as the tumor showed no decrease in size, nor was there any 
permanent improvement in the symptoms. 

Teratoma. — I will only speak of such of these tumors as 
represent the epidermic structures of the body, and of these 
only those known as postrectal and rectal dermoids, including 
under this list (although not properly belonging to it) simple 
cysts. 

Dermoids of the Rectum. — To appreciate the nature of 
dermoids arising in the immediate neighborhood of the rectum, 
it will be necessary to consider a few points connected with 
the embryology of this portion of the alimentary canal. In 
the early embryo, the central canal of the spinal cord and the 
alimentary canal are continuous around the caudal extremity 
of the notochord. This passage, which brings the developing 
cord and gut into such intimate union, is known as the neu- 
renteric canal. When the proctodeum invaginates to form 
part of the cloacal chamber it meets the gut at a point some 
distance anterior to the spot where the neurenteric canal opens 
into it; hence there is for a time a segment of intestine extend- 
ing behind the anus, and termed in consequence the " postanal 
gut." Afterward this postanal section of the embryonic intes- 
tine disappears, leaving merely a trace of its existence in the 
small structure at the tip of the coccyx, known as the coccygeal 



372 DISEASES OF ANUS, RECTUM, AND SIGMOID 

body. There is a good reason to regard the postanal gut as 
the source of that variety of congenital sacrococcygeal tumor 
which was named by Braune (Die Doppelbildungen, 1862) 
and by several writers who followed him " congenital cystic 
sarcoma." These will be referred to as tumors of the post- 
anal gut. In addition, it will be necessary to consider der- 
moids situated between the rectum and the hollow of the 
sacrum, postrectal dermoids, and certain pedunculated tumors 
situated within the rectum, rectal dermoids. 

Tumors arising in the postanal gut exhibit a definite struc- 
ture, being composed of closed vesicles lined with glandular 
epithelium, and containing glue-like fluid. Many of these 
tumors are composed of cysts and duct-like passages lined with 
cubical epithelium, held together by richly cellular connective 
tissue. In many situations the epithelium is columnar, set 
upon flatter cubical cells. The cysts are filled with ropy mucus, 
and vary in size from a nutshell to the smallest space visible to 
the naked eye ; many contain intracystic processes. These 
tumors present such very definite characters that they are sure 
to attract attention, and their large size makes them very 
conspicuous. 

Middeldorpf was the first to associate clearly a congenital 
sacrococcygeal tumor with the postanal gut. His specimen 
was removed from the neighborhood of the anus of a girl one 
year old and contained connective tissue, mucous membrane 
with characteristic follicles, submucous tissue, longitudinal 
and circular layers of muscle fibres. His case is the most 
conclusive on record. 

Postrectal Dermoids. — These, very rare, do not form such 
large projecting masses as the preceding species. In many 
instances not noticed until after infant life, their clinical 
tendencies are moreover of a different character. It is also 
somewhat remarkable that dermoids, although met with in 
many parts of the body, contain teeth only in certain situa- 
tions ; the postrectal region comes into this category. 



PATHOLOGICAL GROWTHS 373 

Such dermoids also occur as surgical surprises, especially 
when they attain very large dimensions and extend upward 
behind the pelvic peritoneum of men and women. Ord recorded 
a remarkable case which occurred in a man of twenty-eight; 
the dermoid weighed fourteen pounds. Page successfully 
removed a dermoid weighing three pounds, which occupied the 
hollow of the sacrum in a woman of forty-seven. It lay 
behind the rectum. 

Skutsch, again, records two examples of postrectal der- 
moids, and collected the chief German cases. One interesting 
from the fact that the patient was pregnant, and he was able to 
empty and partially enucleate the dermoid through an incision 
in the perineum without disturbing the pregnancy. 

Postrectal dermoids sometimes open spontaneously in the 
perineum; the fistula is usually situated in the middle line of 
the perineum near the tip of the coccyx. The student should 
compare pharyngeal and postrectal dermoids; they are prob- 
ably teratomata. 

Rectal Dermoids. — Several examples of dermoid tumors 
have been described growing from the mucous membrane 
of the rectum; a curious feature in these cases is that the 
tumors are furnished with long locks of hair, which protrude 
from the anus and annoy the patient. Like postrectal der- 
moids, they sometimes contain teeth. Danzel observed such 
a tumor in a woman of twenty-five as large as an apple, and 
it was said to contain brain substance enclosed in a bony 
capsule ; a tooth projected from it. This woman was troubled 
with long hairs which protruded at the anus, and she used 
to pull them out with her hands. (J. Bland-Sutton.) 

Treatment. — Let them be removed by carefully dissecting 
them out, under rigid antiseptic technic, and closing the wound, 
or if pedunculated ligate the pedicle and remove the tumor. 

Postanal Dimples. — These occur in the region of the 
sacrum, coccyx, and the posterior margin of the anus, and 
are supposed to be due to imperfect union between the two 
lateral halves of the fetal body. They consist generally of a 



374 DISEASES OF ANUS, RECTUM, AND SIGMOID 

cylindrical depression, which looks upward and backward, 
and ends in a blind sinus, varying in depth from one to several 
inches, or there may be a simple depression without any sinus. 
They are lined with true epithelium and contain sebaceous 
glands and hair follicles. These should be distinguished from 
sinuses occurring in the sacrococcygeal region from obstructed 
sebaceous follicles. 

The author has seen at least half a dozen postanal dimples, 
two of which occurred in twin brothers, who in all respects, 
so far as could be seen, were the exact counterpart of each 
other. 

Treatment. — If the case only consists of a dimple without 
a sinus it may be left alone, but should there be one, especially 
one discharging pus, frequently the case, open it up to the 
bottom, dissect off the surface of the entire channel, and close 
the wound by silk or silkworm-gut sutures, passed beneath 
and outside of the sinus, and draw the edges together. 

Hypertrophied Anal Papillae.- — These normal protuber- 
ances at the upper margin of the anorectal line are subject to 
hypertrophy and under such conditions become very sensitive, 
adding very much to the discomfort of the patient. They 
could in no sense be considered a tumor, but should be removed 
with scissors whenever enlarged and sensitive. 

MALIGNANT TUMORS OF THE RECTUM : CARCINOMAS AND 
SARCOMAS 

Carcinomas. — " Every variety of carcinoma to which 
mucous membranes are subject appears in the rectum and 
sigmoid." 

There are four elementary types of cancer found in the 
anus, rectum, and sigmoid, viz., epitheliomatous, adenoid, 
medullary, and scirrhous carcinomas, malignant adenocarci- 
nomas being the commonest. 

"The rectum, sigmoid, splenic, and hepatic flexures of 
the colon, together with the caecum, are the commonest seats. 



PATHOLOGICAL GROWTHS 



375 



Rectal cancer sometimes extends only to parts about the anus, 
but in other cases it infiltrates the intestines for a considerable 
distance. 

" Intestinal cancer takes the form of soft fungous tumors, 
generally solitary and sharply circumscribed (Fig. 128), or 
spreading over a considerable area (Fig. 129). Infiltration 
of the intestinal wall with cancer-cells usually takes place at 

fr 




Fig. 128. — Photograph of an alcohol specimen showing an adenocarcinoma in the 
form of a superficial papillomatous ulcer beginning just above the anus (A). The ulcer is 
not quite annular. This tumor was removed by Bloodgood in July, 1900. The patient is 
still free from recurrence December, 1909. There was no metastasis to glands. 

an early stage and leads to thickening and induration. If this 
extends round the whole circumference of the bowel, it is 
transformed into a thick-walled rigid tube; the rectum is the 
commonest seat of this indurated change, and, less, frequently, 
the colon. 

" On post-mortem examination of most cases we find the 
surface of the neoplasm already broken clown, leaving a can- 



376 DISEASES OF ANUS, RECTUM, AND SIGMOID 

cerous ulcer with characteristically infiltrated borders. But 
sometimes the borders likewise are disintegrated and eroded, 
and then the ulcer has quite the appearance of an ordinary 
non-malignant inflammatory ulcer. In other cases the borders 
and floor of the ulcer become seared over and shrunken, lead- 




Fig. 130. — Photograph of fresh specimen (by Schapiro). Colloid adenocarcinoma of 
the rectum. Aim, mucous membrane edge of ulcer (Ul); T, the tumor proper has been 
divided; it is about 2 cm. in thickness. It represents a much larger tumor mass than the 
ordinary adenocarcinoma of the rectum. This tumor was removed by Bloodgood in Au- 
gust, 1907, by the combined abdominal and sacral route. No recurrence two years and 
six months since the operation. Age thirty-seven, symptoms 21 months. At first bloody 
diarrhoea, then constipation with ribbon stools. 



ing sometimes to extreme constriction of the bowel; particu- 
larly apt to occur when the ulceration extends in an annular 
form around the intestine (Figs. 130, 131). 

" When a cancer of the intestine breaks down and ulcerates, 
at the same time invading the deeper layers of the wall, it 




Fig. 129. — Painting from fresh specimen of an adenocarcinomatous ulcer just above 
the anus similar in pathology to the one illustrated in Fig. 128. The surface and section 
of the ulcer are shown. White female, aged thirty-nine, symptoms 14 months. Operation 
by Finney, February, 1906. 



PATHOLOGICAL GROWTHS 377 

generally induces inflammatory changes in the serous coat. 
These lead to the formation of new vascular fibrous tissue, 
by which the affected part of the bowel is bound down to the 
surrounding structures. Perforation of the intestine occurs 




Fig. 131. — Photomicrograph (by Schapiro) of the colloid adenocarcinoma shown in 
Fig. 130. A, the dilated and hypertrophied mucous gland; B, colloid areas losing their 
epithelial lining; C, a colloid cyst without epithelial lining; D, an epithelial nest with little 
colloid material. The prognosis for tumors of this character is relatively good. The 
tumor was situated 7 cm. above the anus; it had infiltrated into the perirectal fat. 

in some cases as a result of cancerous ulceration. Metastatic 
growths are met with chiefly in the lymph-glands, peritoneum, 
and liver." (Ziegler. ) 

Seat of the Disease. — According to statistics compiled by 
Tuttle, 4.8 per cent, of all cancers occurred in the rectum. 



378 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Adding to these cases occurring in the sigmoid flexure, the 
percentage is raised to 6.2 per cent. The relative frequency 
with which the different portions of the rectum are affected 
is shown by the same author in the following manner : He 
divides the rectum into four portions : the anal, all that part 
of the rectum below- the internal sphincter; the infraperitoneal, 
from the internal sphincter to the tip of the coccyx, about two 
inches in extent ; the supraperitoneal, from the tip of the coccyx 
to the rectosigmoidal juncture opposite the third sacral ver- 
tebra ; and the sigmoidal extends from this point to the lower 
end of the descending colon. Of these respective portions he 
gives the following results from a collection of 1029 cases of 
cancer. In the anus and rectum it occurred in 901 cases, and 
in the sigmoid flexure 128 were reported. Of those in the 
anus and rectum the seat of the disease has been quite defi- 
nitely stated in 602 cases. The anus was chiefly involved in 
6.7 per cent., the infraperitoneal portion in 26.3 per cent., and 
the supraperitoneal portion in 67 per cent. The fact that 
such a high percentage occurred in the supraperitoneal portion 
demonstrates the fact that a very large proportion of cancers 
of the rectum cannot be extirpated without opening the peri- 
toneal cavity. According to J. Bland-Sutton, of every one 
hundred cases of carcinoma of the intestine, from the begin- 
ning of the duodenum to the anus, seventy-five occur in the 
rectum ; of the remainder, twenty-three would be localized 
in the large bowel, and two in the small intestine, including the 
ileocecal valve. 

" The types of neoplasms found at these various sites in a 
general way were as follows : The squamous or pavement 
epithelioma was found in the anal portion ; the adenocarcinoma 
and medullary cancer in the infraperitoneal and lower portion 
of the supraperitoneal areas ; medullary and scirrhous carci- 
nomas chiefly in the supraperitoneal portion and in the sig- 
moid flexure." (Tuttle.) 

These findings, as might be expected, are subject to 
numerous variations. 



PATHOLOGICAL GROWTHS 379 

I now take up in detail the four elementary types of car- 
cinoma of the anus, rectum, and sigmoid, as previously given. 

Epithelioma. — I confine myself here to the squamous 
variety, occurring chiefly at the mucocutaneous border of the 
anus. I note Ziegler says of this variety: "The flat-celled 
epithelial cancer is characterized by the formation of relatively 
large strings of cells of irregular shape ; but besides these there 
are often small strings of cells, especially in those cases in 
which the cancerous growth has begun to involve the larger 
areas of the mucous membrane. The epithelial cells which 
are massed together in separate collections still show plainly 
the character of the laminated epithelium ; but in consequence 
of their growth and multiplication within the interstices of 
the tissues, they generally assume a variety of shapes and no 
longer manifest their typical characteristics. Very often the 
formation of keratohyalin and the change into a horny con- 
dition takes place deep down in the centre of the large epithe- 
lial plugs ; and along with the process of hornification the cells 
arrange themselves in laminae like those of an onion. Those 
rounded masses of laminated, horny epithelium are called 
epithelial pearls or horny bodies; and hence the name horny 
cancer has been applied to such a tumor " (Fig. 132). 

They begin as slight nodular elevations in the skin or in 
the mucocutaneous surface at the margin of the anus, the 
covering surface of which is not movable over these elevations ; 
their bases are always indurated. After awhile these nodules 
break down and discharge a watery ichorous fluid ; they have 
a distinct tendency to form scabs, and when a scab falls off 
the ulcer increases in circumference and soon other distinct 
nodules form around the edges of the ulceration. This con- 
tinues until the anus is surrounded by these nodular growths, 
or they extend to the perineum or surrounding buttocks, but 
there is little tendency to extend far up into the rectum. As 
a rule, the growth of epitheliomas is very slow, but I have 
observed that, recurring after extirpation, their growth is 
much more rapid. There may or may not be much pain. 



380 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Adenocarcinoma (Malignant Adenoma). — The growth in 
these is made up of glandular recesses lined with tall columnar 
cells ; similar to those lining Lieberkuhn follicles, imbedded in 
a stroma of dense connective tissue. In order to make out the 
nature of the growth, let sections be taken from the margins 
of the tumor, because the deeper points are much altered by 
ulcerative and necrotic changes. 




Fig. 132. — Epithelioma of the anal margin. 



Judging merely from the appearances under the micro- 
scope it would be difficult to determine whether the section 
was prepared from an adenoma or from an adenocarcinoma, 
but it must be borne in mind that the adenoma remains re- 
stricted to the mucous membrane, whereas in adenocarcinoma 
we find the glands with their characteristic columnar cells 
interspersed among the muscular fasciculi of the bowel wall. 
The proportion of connective tissue varies greatly. In some 
adenocarcinomas the glands are closely set; in others ill- 



PATHOLOGICAL GROWTHS 381 

formed, arranged irregularly, and imbedded in an abundance 
of connective tissue. Occasionally collections of lymphoid 
tissue are observed. 

With an invasion of adenocarcinoma of the rectum into 
the anus, the part of the tumor which involves the anus loses 
its glandular character and assumes the squamous-celled form 
(Harrison Cripps). When it invades the peritoneum, this 
serous membrane will sometimes become dotted over with 
minute elevations, like sago grains. " Adenocarcinoma is very 
rare before the age of twenty ; it is commonly met with between 
the thirtieth and fifty-fifth years." (Bland-Sutton.) 

Clinically these growths appear as soft elevated lobular 
masses projecting into the lumen of the bowel. They exude 
the so-called cancer juice, which becomes milky white when 
dropped into water, and may grow very rapidly, attended with 
an abundant discharge of mucus, and often bleed freely (Fig. 

133)- 

Metastasis as a rule takes place early, the liver being the 
seat of secondary deposits in a large proportion of cases. Occa- 
sionally, wide-spread dissemination occurs, and nodules are 
formed also in the lungs, kidneys, and bones. All these sec- 
ondary deposits possess the characteristics of the primary 
growth, namely, the glandular epithelial cells, similar to those 
found in Lieberkiihn follicles. 

Medullary Carcinoma (Soft Cancer). — " In this form the 
cell growth is abundant and predominant, while the stroma is 
inconsiderable." The majority of carcinomas of the rectum 
and sigmoid assume this soft medullary character. 

Clinically it takes the form of soft fungous excrescences, 
or low rounded swellings. As the central parts break down, 
these growths give place to ulcers with raised borders that 
are white and pulpy in appearance. " After the destruction of 
the new growth, fibrous induration of the mucous wall very 
frequently takes place. This form produces many metastases." 
(Ziegler.) 



382 DISEASES OF ANUS, RECTUM, AXD SIGMOID 

" This is the most malignant of all types of carcinoma. 
It bleeds easily, discharges abundant pus, grows rapidly, and 
soon involves the neighboring organs. It ordinarily occurs 
earlier in life than scirrhous. Glandular hrvolvement is earlier 
than in any other form of cancer." (Tuttle.) 

Scirrhous Cancer (Hard Cancer). — This type, the least 
frequent and the slowest of growth of all cancers of the 



Secho OS 
of j-be 




Fig. 133. — Adenocarcinoma (which was removed by the author) possessing these char- 



rectum, has for its most marked feature the overgroAvth of its 
stroma, the cancer cells in such cases being small and com- 
pressed. . It is composed of dense fibrous stroma and epithelial 
cells. The stroma is so arranged as to form a series of alveoli, 
which contain the epithelial cells. 

Clinically these tumors present the condition of a gradually 
contracting- stricture of the rectum or sigmoid. They are 
attended with little or no pain, very little discharge, and no 



PATHOLOGICAL GROWTHS 383 

hemorrhage. Cachexia and sepsis are practically absent, and 
it generally produces death through complete intestinal obstruc- 
tion or rupture of the bowel above the growth. Subject to 
hyaline, mucoid, colloid, and fatty degeneration, melanosis 
has also been observed and calcareous infiltration of the tumor 
is not infrequently seen. It infiltrates the deeper tissues and 
is less likely to recur after complete removal than any form 
of carcinoma. 

Colloid degeneration may develop in any of the four types 
just mentioned. These degenerative changes affect both 
epithelial cells and stroma. When the substance that distends 
the alveoli is more viscid than gelatinous, it is called mucoid 
degeneration. When either of these degenerative changes 
have taken place it is best to consider them under the head of 
gelatinous types of cancer. 

Symptoms. — The symptoms of cancer in the rectum vary 
with the stage of the disease, type of growth, and its location 
in the canal. As a rule, it may be said, the farther they are 
removed above the anal orifice, the longer they are likely to 
remain unobserved. It is astonishing what headway the 
majority have made when first seen by the rectal surgeon. 
While in part due to a want of appreciation of the symptoms 
which should lead to an examination of the rectum by the 
general practitioner, in many instances the symptoms have not 
been sufficiently annoying to cause the patient to even seek 
advice from his family physician. I take this opportunity, 
however, to impress upon the general practitioner the great 
importance of promptly examining the rectum as soon as the 
patient complains of any of the following symptoms. The 
importance of this injunction will be better appreciated when 
the advantages of early operation are shown. Among the 
earliest symptoms frequently recalled by patients are a feeling 
of discomfort in the region of the sacrum or around the 
pelvis ; an increasing tendency to constipation, sometimes alter- 
nating with diarrhoea in a certain number, or to diarrhoea in 
others with slight digestive derangements. The pain, bearing 



384 DISEASES OF ANUS, RECTUM, AND SIGMOID 

down, and a feeling of weight in the pelvis gradually increases, 
until they become so severe that medical advice is sought. 
Frequently by this time, however, the growth is well developed. 
The above symptoms are followed by discharges from the 
bowel of mucus, sometimes streaked with blood; the dis- 
charge is first mucus, followed later by a distinct discharge of 
blood; sometimes the first abnormal discharge is of blood. 
This is likely to contain small clots, and the fluid part is thin 
and watery on account of its admixture with fluid fecal matter. 
These discharges should always lead to an immediate and 
most careful examination of the bowel by the physician. Let 
the rectum be washed out, and make a thorough digital exam- 
ination, assisted by compression of the abdominal walls with 
the left hand, after which the rectum and sigmoid are to be 
carefully examined with the pneumatic proctoscope and sig- 
moidoscope. Where there have been several recurrences of 
bleeding which cannot be accounted for in the lower rectum, 
a negative result following both a digital and a proctoscopic 
examination cannot be regarded as positive proof of the 
absence of a growth higher up the bowel. I recall two such 
cases which I have seen within the last year, where an exam- 
ination with a ten-inch sigmoidoscope failed to discover the 
growth or any abnormal change in the wall of the sigmoid, 
yet, upon opening the abdomen, the upper part of the sigmoid 
was found to be almost obstructed by a carcinoma which 
encircled the bowel at this point. If the growth can be located 
and seen a small portion of it should be removed with speci- 
men forceps, after which it can be examined under the 
microscope and the character of the growth determined. If 
the carcinoma is within reach of the finger, it may be appre- 
ciated at a very early stage, when it is only a small deposit 
beneath the mucous membrane, slightly movable upon the 
muscular wall, making the rectal wall less supple. If the 
growth is seen when only a papillary excrescence, protruding 
into the rectal lumen with an indurated base, it should be 
looked upon with suspicion, being probably an adenocarci- 



PATHOLOGICAL GROWTHS 385 

noma. The thickened indurated rectal wall surrounding a 
growth is one of the most suggestive and earliest symptoms 
of malignancy to be appreciated by touch. 

Dr. George Blumer, of New Haven, Conn., calls attention 
to a very important symptom of an early secondary growth to 
be found in the rectum, generally as a result of metastasis 
from gastric carcinoma to Douglas' pouch, which he desig- 
nates as the rectal shelf. 

" If one passes the finger into the rectum in these cases the 
lower portion of the bowel is usually normal, it is not until 
the prostate gland has been passed that an abnormality is 
detected. Just above the prostate in some cases, in others at 
the limit of palpability, two to four centimeters above, if the 
finger is passed along the anterior rectal wall, it impinges upon 
a shelf of almost cartilaginous feel, which projects into the 
rectal cavity. In some cases further palpation shows that 
the whole rectum is involved in an annular zone of infiltration 
more marked anteriorly and tapering off towards the pos- 
terior wall, a signet ring stricture, as Schnitzler calls it." 

While a similar thickening of the tissues of this pouch 
may be found in cases of diffuse inflammation of the peri- 
toneum, especially diffuse tuberculosis, in the former the infil- 
tration is much more dense and cartilaginous to the feel, while 
in the latter there are accompanying symptoms of general 
tubercular peritonitis which will assist in differentiating the 
two conditions. 

While this condition is a secondary growth an early metas- 
tasis, it is likely to be mistaken for a primary one, especially 
when the symptoms of the latter are very obscure as has been 
shown on several occasions when an operation on the sec- 
ondary growth in the rectum was followed by an operation 
for carcinoma of the stomach in less than a year. 

A scirrhous carcinoma of the rectum or sigmoid in its 
early stages, especially before it has undergone degeneration, 
resembles very closely a simple fibrous stricture. The history 
of such a case may materially help in making the diagnosis, 

25 



S86 DISEASES OF ANUS, RECTUM, AND SIGMOID 

as simple inflammatory strictures are nearly always preceded 
by traumatism, ulceration, or suppuration. 

In the active or proliferative stage of these tumors, the 
symptoms are much more marked. In scirrhous or annular 
carcinoma, which is chiefly met with in the upper rectum and 
sigmoid, gradually increasing constipation is a typical 
symptom. 

If within reach of the finger, and it can frequently be 
brought within reach by firm pressure on the lower part of the 
abdomen with the other hand, the sensation of a dense, inelas- 
tic, nodular mass is imparted to it, with the lumen of the 
bowel very much contracted. 

An entirely different picture is presented in the second 
stage of adenocarcinoma. Here we have as a rule frequent 
calls to defecation, resulting in considerable straining, with 
the passage of gas, with small amounts of mucus, with or 
without blood. These frequent calls to the toilet may have to 
be repeated from ten to fifteen times during the day, with no 
satisfactory results. Usually this tendency to diarrhoea is 
quiescent during the night, but the patient is almost invariably 
called to evacuate immediately upon rising in the morning. 
The first two or three early morning stools consist almost 
entirely of mucus, pus, and blood; after which the patient 
may have a very satisfactory fecal movement, followed by a 
return of the teasing and unsatisfactory mucous discharges 
for the remainder of the day. Hemorrhages may be frequent 
and slight, or occasional and large ; in the former case the 
blood is likely to be dark, very thin, grumous, resembling prune 
juice in color, with a distinctly characteristic odor often very 
offensive. When the hemorrhage is large, the blood will be 
dark if it has remained in the bowel for any length of time, 
and grumous, but if passed soon after its discharge into the 
bowel it will be bright red, and generally indicate that the 
growth is low down in the bowel. 

Pain is likely to be very marked at this stage. It may be 
dull, vague, and shooting down the extremities, or sharp and 



PATHOLOGICAL GROWTHS 387 

burning; frequently influenced by posture, but not following 
any definite rule. It is generally increased by the act of 
defecation, and is more constant and decided the nearer the 
growth approaches to the sphincters. When the sphincters 
are involved in the growth, there is likely to be incontinence 
of faeces. 

A digital examination in these cases reveals a variety of 
conditions. Sometimes a hard lobulated mass protrudes into 
the rectum from almost its entire circumference; at others it 
may be attached only to a small portion of the same ; the mass 
may be a proliferating cauliflower-like growth ; or there may 
be a deep excavating ulcer with its base and the walls of the 
bowel indurated throughout its entire circumference to such 
an extent as to produce a narrowing of its calibre. 

At this stage the constitutional symptoms are likely to be 
very marked, such as loss of flesh, anaemia, increasing sallow- 
ness of the skin, and loss of appetite. 

In the medullary type the symptoms are even more marked, 
the pain greater, the discharge more profuse, and of a fetid 
gangrenous and disgusting odor, the constitutional symptoms 
much more pronounced and rapid in showing themselves. A 
digital examination reveals a dense ulcerated mass with sharply 
defined edges, surrounding a crater-like cavity. Sometimes 
it comes in contact with a soft brain-like mass, which may be 
isolated and easily broken down. The proctoscope may also 
help to show up these conditions when beyond the reach of 
the finger, but as a rule much more can be learned from a 
digital examination. 

With the increase in the growth the adjoining organs 
become involved and their functions interfered with. 

I had an inoperable case of carcinoma of the rectum, on 
which I did a left inguinal colostomy, and after several weeks 
of comfort both ureters became involved, and the patient did 
not pass any water into the bladder for four or five days prior 
to her death. 



388 DISEASES OF ANUS, RECTUM, AND SIGMOID 

All of the above symptoms continue to increase until death 
closes the scene, either from a general septicaemia or complete 
obstruction of the bowel. The latter rarely occurs, either 
because it is anticipated by a colostomy, or because the types 
of cancer which occur most frequently in the rectum, viz., 
adenocarcinoma and medullary carcinoma, are soft, friable, 
and ulcerate chiefly upon the surface, thus keeping the calibre 
of the bowel opened. This accident, however, is always immi- 
nent in carcinoma of the sigmoid, where the type of the malig- 
nant growth is most frequently scirrhous. I recall one case 
of death in my own experience from complete obstruction by 
this type of carcinoma, which occurred in the lower portion of 
the sigmoid. 

Another cause of death in many of these forms of car- 
cinoma, but especially in the scirrhous, is rupture of the bowel 
just above the growth, which in turn is due to the obstruction 
offered by the malignant growth to the passage of fecal matter, 
the consequent distention of the bowel above this point, and 
its subsequent ulceration. 

Perirectal abscesses are likely to develop in the later stages 
of carcinoma of the rectum, which may result in fistula, or 
open into adjoining organs. These collections of pus are likely 
to be accompanied by septic symptoms, such as high tempera- 
ture and chills. They may result in extensive gangrene and 
sloughing. 

From the extensive inflammatory conditions around the 
growth, the rectum is likely to become attached to the adjoin- 
ing organs and pelvis without being involved in the malignant 
growth, at least in the early existence of such attachments. 

Manner of Extension. — " While sarcomas exhibit a 
predilection to extend by means of the circulatory system, 
carcinomas show a similar selection of the lymphatic system 
for extension. This does not mean that carcinomas cannot 
form metastases along the vascular channels. In general the 
cells infiltrating the lymph spaces of a tumor find their way 
thus into the lymph channels, and then either by continuous 



PATHOLOGICAL GROWTHS 389 

growth along those channels or by becoming detached are 
found in the group of lymph glands draining the region 
affected." (Adami.) 

In epitheliomas involving the anal canal the disease extends 
by continuity to the surrounding perineum, scrotum, vulva, 
and ischiorectal fossa. The lymphatic involvement in these 
cases travels in the line of the inguinal vessels and glands, 
where the enlarged glands can always be found. " When the 
disease involves the ischiorectal fossa, the lymphatic extension 
is along the line of the middle hemorrhoidal lymphatics, and 
from the latter the hypogastric chain of glands become in- 
volved." (Quenu and Hartmann.) 

When the carcinoma appears in the subperitoneal portion 
of the rectum, the extension involves the prostate, the seminal 
vesicles, bladder, urethra, or the vagina and uterus. In this 
case the retrorectal and hypogastric chain of glands also 
become involved. 

If the supraperitoneal portion of the rectum and lower 
sigmoid are the seat of disease, the peritoneum, uterus, and 
bladder are in the line of extension. Sometimes it may involve 
the pelvic bones. The line of lymphatic extension in this case 
is sometimes the hypogastric, but generally the anterovertebral 
chain. 

The liver is the most frequent seat of secondary deposits. 

Diagnosis. — I spoke before of the association of the 
benign and the malignant adenomata side by side in the same 
case, and of the importance of examining each growth re- 
moved in order to determine malignancy. Let me here go 
further and say that the examination for each growth is not 
complete until sections are examined from their bases, " as 
it has been found that the superficial portions of the growth 
do not show any appearance of malignancy, while their base 
does." (Tuttle.) 

Although some probability of confounding carcinoma of 
the rectum with proliferating proctitis exists, the latter gen- 
erally has a history or some symptoms of syphilis ; the dis- 



390 DISEASES OF ANUS, RECTUM, AND SIGMOID 

ease is uniformly distributed throughout the rectum; diar- 
rhoea is also present from the beginning, the discharge of 
mucopus is abundant; the protruding granulations are also 
soft to the touch and without any indurated edges. 

To distinguish between a simple fibrous stricture and a 
scirrhous carcinoma is very difficult, except by microscopic 
examination after excision. Difference in locality is probably 
one of the most distinguishing features. The scirrhus rarely 
appears in the rectum, while fibrous stricture is quite as rare 
in the sigmoid. It would not be well, however, to place much 
dependence on this distinguishing characteristic. There is a 
decided difference between the appearance of the mucous 
membrane over each as seen through the proctoscope. Over 
scirrhus the mucous membrane appears congested, thickened, 
or ulcerated; while over fibrous stricture it is pale, smooth, 
shining, and rarely ulcerated. 

Epithelioma of the anus may be mistaken for fissure or 
tubercular deposits. From fissure it can readily be diagnosed 
by the small amount of induration beneath the sore. It may 
readily be differentiated from tubercular deposits by there being 
no tendency to the formation of sinuses or fistulse. It is, 
however, much more satisfactory to rely upon microscopic 
examinations for a positive diagnosis. 

When the carcinoma is situated high up in the sigmoid, 
and it is impossible to obtain sufficient data through the rectum 
to make a diagnosis, it is perfectly justifiable to make an 
exploratory incision into the abdomen for that purpose when 
serious symptoms justify the procedure. When making such 
an incision, be prepared to do whatever is necessary for the 
relief of the patient. 

Treatment. — Carcinoma of the rectum and sigmoid pre- 
sents to the rectal surgeon the most serious and difficult prob- 
lem in his field of work. In the rapid advance which surgery 
has made in the last few years it is no longer necessary with 
an antiseptic technic to weigh the pros and cons of operating, 
but merely to decide in each individual case whether or not 



PATHOLOGICAL GROWTHS 391 

the malignant growth has advanced beyond that stage of 
development when a fair hope for prolonged immunity or 
permanent cure would be effected by its complete extirpation. 

The old method of temporizing with these cases by pallia- 
tive measures is no longer to be tolerated. The question to 
be decided from the very first, and to be done with as little 
delay as possible, is shall I operate or not? If inoperable then 
attention should be turned to making the patient as comfort- 
able as possible. If operable, then an immediate decision 
should be made as to the operative procedure which will give 
the best results, i.e., the most complete eradication of the 
disease, least liability to recurrence, and greatest amount of 
comfort to the patient. 

What conditions will enable us to decide whether or not a 
case is operable? Surgeons differ so widely as to indications 
determining this matter that it is a very difficult question. 

The technic for the combined perineal and abdominal 
routes have been so definitely defined and excision by this 
method so successfully done at all points from the anus to 
the upper sigmoid, that location of the malignant growth no 
longer influences the answer. To me it seems to resolve itself 
into determination of the stage in the development of the 
malignant growth ; the alliances it has made with other organs, 
and whether there are any metastases. 

What has previously been said in this chapter about the 
different stages of carcinoma of the rectum should enable 
the surgeon to decide this part of the question fairly well. 

If the growth is within reach of the finger, or can be 
brought down within its reach by counter-pressure on the 
abdomen, the attachment or extension to other organs, or to 
the framework of the pelvis, can also be made out fairly well. 
The mere attachment of the diseased rectum, however, to other 
organs or to the framework of the pelvis by simple inflamma- 
tory adhesions is not sufficient to impair the good results of 
a complete excision, but it is necessary the malignant growth 
should have extended to and involved the attached oro-an or 



392 DISEASES OF ANUS, RECTUM, AND SIGMOID 

pelvic framework. The decision of this question can only be 
approximated by the firmness of the adhesions, but it can be 
more definitely determined by the presence of some of the 
characteristic symptoms of the malignant growth in the 
attached organ or pelvic framework. The existence of metas- 
tasis, except to the adjoining lymph glands, is not likely to 
be recognized in the earlier stages, especially as the organ 
most frequently affected by these secondary growths is the 
liver, in which its early recognition is difficult. 

Inoperable Cases. — A case may be said to be inoperable 
when the rectum or sigmoid is firmly attached to its neighbor- 
ing organs or to the general framework of the pelvis ; when 
the neighboring organs or the general framework of the pelvis 
shows evidences of involvement by the malignant growth, or 
the adjoining lymph glands — those in the line of extension of 
the disease — are enlarged, or when there are evidences of a 
general involvement of the system, either by the direct effects 
of the malignant growth, as by numerous metastases, or by its 
secondary effects as general septicaemia. 

Palliative Treatment. — When a case is decided to be inop- 
erable, attention should be turned towards making the patient 
as comfortable as possible, and mitigating the ill effects of the 
disease both local and constitutional. This is the only class 
of cases in which palliative treatment is admissible, except 
when it is needed preparatory to an extirpation. 

The. patient's diet, while varied, consists of articles least 
irritating to the ulcerated surfaces of the tumor, nor likely 
to form hard scybalous masses, yet at the same time very 
nutritious; milk is prohibited, except in very moderate quan- 
tities with fruits and cereals, on account of its tendency to 
form hard scybalous masses ; this objection, however, does 
not apply to buttermilk, which is also more digestible. Eggs, 
fresh rare meats, fruits (fresh and cooked), and such vege- 
tables as do not contain much coarse cellulose can be given. 

Irrigation. — Probably the one most important thing to be 
done in the treatment of these cases is to keep the rectum 



PATHOLOGICAL GROWTHS 393 

free from accumulations of mucopus, blood, and detritus. 
This is best accomplished by frequent irrigations (two or 
three times daily) with plain tepid water, to which some bland 
and non-irritating antiseptic may be added. Probably the 
best is boracic acid, one dram of the powder to one pint of 
warm water, or the same amount of antiseptic powder N. F. 
The chief point to be gained, however, is washing out the 
bowel. 

If the growth is low down in the rectum the patient should 
be placed in the left lateral position ; if high up and the patient 
is weak, he should be placed in the same position with the 
hips elevated and the shoulders lowered, or if he is strong 
enough the knee-chest position would be better. The water 
should be allowed to run in slowly, and when the bowel is full 
it is best to let the patient evacuate it on the toilet if he is 
sufficiently strong, as he will empty the contents of the bowel 
more thoroughly in this position ; but if not equal to this, it is 
better to use a rectal irrigator. If these measures do not 
relieve the frequent tenesmus and there is much pain, it will 
be necessary to give opium ; but only as the symptoms demand, 
so as to conserve its effects as long as possible. 

In cases of medullary carcinoma and probably in some 
cases of adenocarcinoma when attended with exhausting hem- 
orrhages, it would be better to curette the growth in order to 
get rid of the soft pulpy material. The curettage may be 
followed by hot-water irrigations, in order to control the 
bleeding. 

Colostomy as a Palliative Measure. — While opinions 
vary greatly among surgeons as to the propriety of doing a 
colostomy as a palliative measure, yet there are a group of 
symptoms which the majority think justify it when present, 
namely, danger of intestinal obstruction, frequent stools with 
tenesmus, and bearing down. The surgeon can give every 
assurance to the patient that these symptoms will be very 
greatly benefited and much more comfort given. In addition 
there is a strong probability that the extension of the malig- 



394, DISEASES OF ANUS, RECTUM, AND SIGMOID 

nant growth may be much controlled by removing the irri- 
tating influence of the fecal matter from the ulcerated surface. 

There can be no question of the advantages thus gained 
for irrigating the entire bowel below the colostomy wound, 
and thus decidedly lessening the absorption of septic material ; 
nor will the fecal discharges from the colostomy wound be 
nearly so frequent or troublesome as from the natural passage 
under existing conditions. I am convinced that such good 
results call for this procedure far more frequently than it is 
now taken advantage of. 

For the same reasons and under the same conditions 
entero-anastomosis may be substituted for colostomy, and 
thus do away with the disadvantages of an artificial anus. 
This is feasible where there is sufficient healthy bowel below 
the growth to admit of an anastomosis between the rectum 
or lower sigmoid and the upper portion of the sigmoid, the 
caecum, or the ileum. This operation is chiefly employed for 
inoperable tumors above the sigmoid flexure. 

The procedure consists in a lateral anastomosis between 
two segments of the bowel, using either Abbe's method or the 
Murphy button. By either of these methods the portion of 
the bowel involved in the disease retains its connection with 
the rest of the intestine and a certain amount of the intestinal 
contents passes through it. A second method consists in 
cutting out the portion of the bowel that contains the malignant 
growth, including several inches of healthy bowel on each side 
of the growth. The two ends of the diseased portion are 
invaginated and closed by Lembert sutures. The healthy seg- 
ments above and below the growth are united by an end-to-end 
anastomosis, either by suturing them or by using a Murphy 
button. By the latter method, the diseased portion of the 
bowel is cut out entirely from the fecal current. 

With regard to the X-ray as a curative measure in carci- 
noma of the rectum, one which gave so much hope from the 
good results derived in the treatment of skin epitheliomas, it 
has been found after repeated trials to have positively no 



PATHOLOGICAL GROWTHS 395 

effect in retardation, or in any way suggesting curative action 
where the growth extends above the anal margin. Radium has 
been found equally inefficient in the treatment of cancer of 
the rectum. 

Operable Cases. — A case is said to be operable when 
the malignant growth is confined to the rectum or sigmoid, 
regardless of its location in any part of them and where there 
are no evidences of metastasis in other organs. 

An operation for carcinoma of the rectum always implies 
an excision or a resection of the affected parts. The pro- 
priety of such a procedure in properly selected cases, as above 
designated, is now thoroughly justified by both immediate and 
remote results following the modern methods. The route to 
be selected depends upon the location of the malignant growth, 
and this in turn materially affects the success of the operation. 

The different routes selected are the perineal for car- 
cinomas low down, the mortality of which is comparatively 
low ; the sacral for carcinomas in the upper rectum and lower 
sigmoid, the mortality of which is fairly low, if the operation 
is done only in those cases in which the growth is confined to 
the rectal wall; the abdominal for carcinomas in the middle 
and upper portion of the sigmoid; and lastly, the combined 
sacral and abdominal route for those cases in the upper rectum 
and lower sigmoid which are rather over the border-line of 
strictly operable cases, made so by inflammatory attachments 
to the adjoining organs or pelvic framework, but in which the 
malignant growth has not extended to> them. 

The technic of these different routes will be taken Up in 
detail in the succeeding chapter. I only discuss here the results 
in general of operations by these different routes to ascertain 
if results justify the claims recently made for operation. 
Tuttle has shown in his " Diseases of the Anus, Rectum, and 
Pelvic Colon " (page 785) a mortality of 20.2 per cent, from 
a total of 1578 cases of extirpation of the rectum clone since 
1880, and collected from literature and private communica- 



396 DISEASES OF ANUS, RECTUM, AND SIGMOID 

tions. This Tuttle asserts is practically the conclusion of 
Finet, from a collection of three hundred and seventy-five 
cases. 

A paper on " Cancer of the Rectum " read by Tuttle 
before the American Medical Association, June, 1908, showed 
a mortality of only 13 per cent, in one hundred cases of exci- 
sion of the rectum done by himself. There are also other 
very interesting data in this same paper, which is well worthy 
of careful perusal, but which cannot be given here in detail. 

I would supplement these reports by reference to four 
cases in my own practice, three on which I did an excision 
of the rectum for adenocarcinoma, all of which are alive with 
no recurrence, one after twelve years, one after ten years, and 
the third after three years ; also one case of excision for small 
spindle-cell sarcoma, who is alive with no recurrence after 
eleven years. 

Enough, I think, has been given to justify the claim made 
in a previous paragraph for excision in properly selected cases, 
and the results stand out in bold contrast to the gloomy picture 
so often presented to those familiar with the usual course of 
cases allowed to terminate without an operation. 

SARCOMA 

" A sarcoma is really a cellular tumor of the connective- 
tissue type, the cells being of the vegetative, imperfectly differ- 
entiated order, or embryonic ; and the component cells develop 
and present characteristically interstitial substance. The more 
embryonic the type of cell-standard, the greater the malig- 
nancy. All sarcomas present certain features in common. 
They are not encapsulated, but exhibit a peripheral growth, 
and invasion of the surrounding tissues. This invasion is 
along the tissue spaces and leads to progressive destruction of 
the pre-existing tissue, with general absorption of all that 
tissue save a supporting framework around the vessels and 
capillaries. 

" The sarcoma cells, in short, grow in the immediate neigh- 
borhood of the capillaries. This is a marked feature of all 



PATHOLOGICAL GROWTHS 397 

sarcomas. We observe throughout the tumor that the vessels 
are composed of a single endothelial layer, immediately 
beneath which are tumor cells. The capillaries may be widely 
dilated, in fact, another feature is the abundant vascularity of 
the growths. 

" From these relationships it will be readily understood 
that (i) hemorrhages into the tumors are very apt to occur, 
and (2) that sarcoma cells are liable to become free in the 
blood-stream, and that metastases along the blood-stream are 
characteristic of these grozvths. Such metastases, it must be 
remembered, are not confined to the vascular system ; they may 
occur along the lymphatics, so that malignant enlargement 
of superficial and other lymph glands is not absolutely diag- 
nostic of cancer. 

" But extension by the blood-vessels is undoubtedly the 
commonest procedure, and thus it is that a secondary sar- 
comatous growth is peculiarly apt to show itself in the lungs. 
So also it must be noted that the growth may directly invade 
and grow along the blood-vessels. 

" The frequency with which sarcomas are melanotic is not, 
as has been supposed, due to the thinness of its blood-vessel 
walls, and thus to any relationship between the melanin and 
haemoglobin, but the modern view regards the melanin as a 
derivative from nucleolar matter of the nuclei of the melanin- 
bearing cells (Rossle, Meirowsky, StafTel), associated with 
distinct signs of nuclei exhaustion, not to say degeneration. 
It may well be that the extraordinary deposit of melanin in 
melanotic tumors, far from being a progressive acquirement, 
indicates a deficiency in the disintegrative mechanism of the 
cell, whereby the normal final stage of colorless chromogen 
formation, or of protein disintegration, is not reached." 
(Adami.) 

So frequent are melanotic sarcomas in the rectum, that 
they stand in the ratio of two to one to non-melanotic ; whereas 
melanotic carcinomas in the rectum are very rare. 



398 DISEASES OF ANUS, RECTUM, AND SIGMOID 

" The species are determined according to the prevailing 
type of cell : thus we have round-celled and spindle-celled sar- 
comata; some contain pigment, and are known as melanosar- 
comas. Of each of these there are one or more varieties, 
which have received qualifying names, such as lymphosar- 
comata, myosarcomata, chondrosarcomata, etc." (J. Bland- 
Sutton.) 

Sarcomata as found in the rectum are irregular deposits 
beneath the mucous membrane; their surface is rough and 
unequal, and the mucous membrane is movable over the 
growths in their early stages, but subsequently it may become 
adherent to the growth, through inflammatory processes. 
They may be single or multiple, and are generally sessile and 
may become pedunculated as the result of traction by the 
peristaltic movements of the bowel, or from their own weight, 
or they may appear as a circumscribed fibrous thickening of 
the wall of the bowel. 

Varying in size from one to four or five inches in diam- 
eter, they are not so dense as scirrhous carcinomas, except in 
cases of fibro-osteosarcomas. 

When melanotic they appear as black gangrenous masses, 
although when multiple one tumor may be melanotic while 
the other may present the ordinary color of mucous membrane. 

They may appear in any portion of the rectum or sigmoid 
(the only case operated upon by myself was located in the 
lower portion of the sigmoid), but are generally located in 
the lower portion of the rectum, or in the anal canal. 

They increase in size much more rapidly than do carci- 
nomas, and prove fatal much sooner. 

According to Ziegler, the sarcomas possess no lymph 
vessels proper, only occasional lymph spaces and channels. 
Notwithstanding, we sometimes find enlargement of the 
adjoining lymph glands, which is said to be more frequent in 
sarcomas of the rectum, but the fact must not be overlooked 
that metastasis from sarcoma usually takes place through the 
blood-vessels, especially the veins. These metastases in sar- 



PATHOLOGICAL GROWTHS 399 

coma are not only very frequent, but likely to involve many of 
the organs. In sarcomas of the rectum, the liver stands in 
the direct line of infection through the portal circulation, and 
therefore is most frequently the seat of secondary infection. 

Sarcomas of the rectum may be either primary or sec- 
ondary, the latter as a result of metastasis from tumors else- 
where in the body. 

The types of sarcoma most frequent in the rectum are the 
round-cell, spindle-cell, and alveolar. 

Hemorrhages occasionally occur in these tumors, owing 
to the thinness of the blood-vessel walls, the dark appearance 
of which must not be mistaken for melanosis. 

Age. — While the majority of cases of sarcoma occur after 
middle life, yet they do occur in very young children. 

Symptoms. — The early symptoms are very similar to those 
of any growth, probably at first a fulness, with a disposition to 
bear down, a discharge of mucus, sometimes blood ; in the 
later stages the bleeding may be very excessive, but not, 
however, until degeneration sets in, after which there is also 
a considerable discharge of pus. Protrusion of the tumor if 
pedunculated, or located directly at the anal margin, is not 
uncommon. 

There is never any very pronounced odor in the discharge, 
even after ulceration of the growth has set in, such as found 
in carcinoma of the rectum. 

Pain. — The amount of pain attending sarcoma of the 
rectum depends largely upon its location. If low down in 
the rectum, especially if involving the sphincters, the pain is 
very severe, but if high up in the rectum or sigmoid the pain 
is likely to be very slight. 

The condition of the bowels varies with the stage of the 
growth and its location. Where there is much pain, increased 
by the act of defecation, the patient is likely to restrain his 
movements and the bowels are apt to be constipated, but during 
the later stages, attended with ulceration, there is likely to be 
diarrhoea. 



400 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Cachexia is not likely to be nearly so marked as in car- 
cinoma. 

Diagnosis. — The infiltration of the walls of the bowel in 
sarcoma does not extend as far out around the growth as in 
carcinoma. In the early stages of sarcoma, the fact that the 
mucous membrane moves easily over the growth is a char- 
acteristic condition which distinguishes it from carcinoma. 
But the most certain method of making a diagnosis is by a 
microscopical examination of a section taken from the body 
of the tumor and not from its mucous covering. 

Treatment. — This consists in a radical excision of the 
growth, the incision for which should extend well beyond the 
base of the tumor, and even include excision of the rectum, if 
the growth involves much of its walls. 

The technic of the latter procedure will be considered in 
the chapter on Extirpation. 

As in carcinomata, except in epithelioma of the anal 
margin, the X-ray or radium treatment offers no hope in the 
treatment of sarcomas. 

Prognosis. — The prognosis is most grave, even in cases 
operated upon, as metastases are likely to take place early in 
the disease and prove rapidly fatal. The case of a spindle- 
cell sarcoma, probably the least malignant type, of the lower 
sigmoid, on which the author did an excision, has however 
survived eleven years without any recurrence of the disease. 



CHAPTER XVI 
EXTIRPATION OF THE RECTUM 

This, so important an operation, demands a separate 
chapter. 

Practised for nearly two centuries, it was not until after 
the introduction of antiseptic surgery that its success was 
sufficient to encourage its being performed, and up to 1876 
the operation was confined to* growths low down in the rectum 
and was performed either through a perineal incision or the 
anus itself. 

Verneuil, at the suggestion of Amussat, first practised 
the removal of the coccyx to obtain more room for the removal 
of the tumor. The operation obtained very little popularity 
until Kraske read his paper before the Fourteenth Congress 
of German Surgeons in Berlin in 1885, in which he suggested 
the removal of a portion of the sacrum for this purpose. Fol- 
lowing his suggestion, many notable surgeons advocated 
removing even larger portions of the sacrum, until it included 
the entire bony floor of the pelvis. The rebound from this 
extreme was championed by such men as Billroth, Levy, and 
others, who substituted bone-flaps containing the coccyx and 
lower segments of the sacrum, which were to be sutured back 
in position after the rectum was extirpated. 

This was followed by a suggestion from Desguins to 
employ the vaginal route in extirpating malignant growths of 
the rectum (Annates de la soc. de med. d'Anvers, September, 
1890). Price (Med. and Surg. Reporter, May 16, 1896) 
and Arthur (Amer. Jour, of Obstet., Vol. XXIV, page 567) 
had previously made use of the vagina as a point for the 
implantation of the bowel after extirpation of the rectum, 
where it was impossible to bring it down and suture it to the 
margin of the anus, but neither of them suggested attacking 
the growth through this canal. 

26 401 



402 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Subsequently Giordano and Quenu (Clinica Chirurg. 
Milano, 1896, f. 463; CJiinirgie du red., t. ii, page 290) 
advocated opening the abdomen to loosen the attachments of 
the upper rectum and sigmoid and to establish an artificial 
anus ; after which the rectum was dissected out, either through 
the perineal or sacral route. This was known as the combined 
method of extirpating the rectum. 

Maunsell preceded them by an almost similar suggestion in 
1892, except that after loosening the upper rectum and sig- 
moid he further advised invagination of the growth through 
the anus and resection of the growth thus brought outside of 
the body. 

It will thus be seen that there are five general methods of 
performing extirpation of the rectum, perineal, sacral, vaginal, 
abdominal, and the combined. 

Preparation of the Patient. — It is very necessary that 
this should be done carefully, as results depend much upon it. 
The patient's strength and general condition must first be 
considered, due care being taken to improve it as much as 
possible. The condition of the bowels must next be most 
carefully noted. In the majority of cases they will be over- 
loaded, even though in certain cases there may have been 
frequent or even constant oozing. In order to avoid any risk 
of possible rupture of the bowel by a strong cathartic in case 
the growth has produced a stricture with ulceration of the 
coats of the bowel, it is better to give moderate doses of a 
gentle laxative, either castor oil or compound liquorice powder, 
and repeat this frequently until the bowels are thoroughly 
emptied. 

The diet must be so regulated as to be as concentrated, 
nutritious, and devoid of refuse as possible. Milk should be 
restricted, or better omitted, on account of its tendency to 
produce hard scybalous masses ; buttermilk, however, may be 
substituted. Eggs may be allowed with a small quantity of 
meat (better fish) and bread. The food should be given in 
small quantities, and at frequent intervals. An effort should 



EXTIRPATION OF THE RECTUM 403 

be made to disinfect the intestinal canal from above, by giving 
salol or beta-naphtol, in x grs. doses, or sulphocarbolate of 
zinc, grs. ii, three or four times daily between meals. 

Let the rectum be irrigated from two to three times daily 
with mild antiseptic solutions, as antiseptic powder N. F. one 
dram to one pint of water, or the same strength of boracic 
acid. These should be given in the knee-chest position or with 
the hips well elevated. These preliminary preparations should 
be begun and continued for four or five days, or even a week, 
if the time can be afforded prior to the operation. The usual 
toilet just previous to the operation must, of course, be made, 
when the rectum should be irrigated with a solution of for- 
malin 40 per cent., using 5i to 1 quart of tepid water. 

The practise of making a temporary artificial anus for the 
purpose of obtaining more complete asepsis in the portion of 
the bowel to be operated on, so frequently done a few years 
ago, is now being abandoned, principally on account of its 
curtailing the length of bowel that may be needed below to 
replace the excised portion, and on account of its necessitating 
two distinct operations (opening and closing of the artificial 
anus) in addition to that for the excision of the growth. 
Bloodgood, of the Johns Hopkins Hospital, reflects the present 
advanced views on this subject in the following paragraph : 

" Colostomy has been performed too frequently as a pri- 
mary operation. It is not indicated unless the patients are first 
seen in a condition of acute obstruction, or their condition is 
so critical from chronic obstruction that a prolonged operation 
is contraindicated. If possible, the entire operation should be 
performed at one sitting." 

There is a certain class, however, in which it may be best 
to do a temporary colostomy, as in cases where it is not likely 
that the operator will be able to bring the bowel down from 
above and suture it to the margin of the anus. The propriety 
of doing a permanent colostomy in inoperable cases of cancer 
of the rectum is not to be considered in this connection. In 
those cases, where a temporary colostomy is thought advisable, 



404 DISEASES OF ANUS, RECTUM, AND SIGMOID 

it should be done for ten days or two weeks before the pro- 
posed operation for excision, in order that the diseased portion 
of the bowel may be thoroughly irrigated from above prior 
to the operation. 

In cases of soft carcinomas of the rectum, where there is 
considerable ulceration and breaking down of the tissues, 
attended by an excessive and very fetid discharge, it would be 
better to scrape the ulcerated surfaces with a curette several 
days prior to the operation. This to be followed by a con- 
tinuation of the antiseptic irrigations. 

Perineal Method. — This method is used in extirpation of 
malignant growths of the rectum, within four inches of the 
anal margin. 

Of the various methods suggested from the time of Diffen- 
bach, Velpeau, and Verneuil to the present for performing this 
operation, that of Quenu, with certain modifications by Tuttle, 
appeals to me most strongly, as one best calculated to meet 
modern requirements. The following is their method, with 
illustrations from Tuttle and certain modifications by the 
author. 

The rectum having been thoroughly irrigated and the 
external parts properly prepared, the rectum is then lightly 
packed with dry sterile gauze. The patient is placed in the 
extreme lithotomy position and the hips well elevated; a cir- 
cular incision is made through the skin, just below the muco- 
cutaneous border, and this is dissected up through the anal 
canal just above the external sphincter. A slip-knot loop of 
tape is thrown around the part of the cylinder thus dissected 
loose and drawn tight (Fig. 134), the ends being left long 
for the purpose of traction. The external sphincter is incised 
anteriorly and posteriorly entirely outside the rectum, the pos- 
terior incision being carried back to the tip of the coccyx and 
well into the retrorectal space; the rectum is dissected from 
its attachments laterally and posteriorly, the sphincter being 
left in the skin-flaps, if not involved in the growth; in doing 



EXTIRPATION OF THE RECTUM 



405 



this the levator ani muscle should be cut off as close to the 
rectum as possible (Fig. 135). The skin and sphincter muscle 
having been incised in the median line anteriorly as far as the 
junction with the scrotum, the rectum is drawn backward and 
dissected loose anteriorly up to the level of the levator ani, 
which is much higher here than posteriorly. The ringer is 
then introduced from behind forward above the anterior fibres 






Fig. 134. — Perineal extirpation of the rectum (Quenu's method). R, rectum; £, external 
sphincter; C, coccyx; T, transversus perinei muscles; A, bulbous urethra. (Tuttle.) 

of the levator ani and the deep perineal fascia, and by gently 
dragging downward these are separated from the rectum in 
the lines of cleavage. When, this has been accomplished on 
both sides, the anterior attachment of the levator and ano- 
bulbar raphe to the rectum are cut through upon the finger, 
and the organ thus freed in its entire circumference. This 
accomplished, the operator reaches the superior pelvirectal 
spaces filled with cellular tissue, from which the rectum can 



406 DISEASES OF ANUS, RECTUM, AND SIGMOID 

be separated by the finger until the peritoneal cul-de-sac is 
reached in front. At this point the lateral connective-tissue 
folds which support the rectum on the sides must be clipped 
with scissors, and then the gut will descend well outside the 
wound. Sometimes the peritoneum can be stripped off from 
the rectum and its cavity need not be opened ; it is better, how- 
ever, to open the cavity at once when the growth extends 



~~~3 




Fig. I3S-- 



-Perineal extirpation — loosening rectum from anterior perineal rhaphe. L, leva- 
tor ani; R, rectum; M, rhaphe. (Tuttle.) 



above this point. Before doing this it is well to disarticulate 
the coccyx and fold it backward in order to obtain more room 
and separate the rectum from the sacrum by breaking up the 
cellular and fibrous attachments with the fingers. The peri- 
toneum is then incised (Fig. 136), cut loose from its attach- 
ments close to the rectum back to the mesorectum, which should 
be cut close to the sacrum in order to avoid wounding the 
inferior mesenteric artery. When the bowel has been loosened 



EXTIRPATION OF THE RECTUM 407 

sufficiently above the tumor to be brought down and sutured to 
the anus, one should proceed to close the peritoneum and 
restore the planes of the pelvic floor down to the levator ani 
by fine cat-gut sutures. The rectum is then amputated through 
healthy tissue at least one inch above the tumor, and its upper 
end sutured at the original site of the anus on each. side. The 
posterior and anterior portions of the perineal wound are 



Fig. 136. — Perineal extirpation — the peritoneal pouch laid open. (Tuttle.) 

closed with stout silk sutures and a cigarette drainage-tube is 
introduced at each extremity of the wound to insure drainage 
(Fig. 137) ; the parts are covered with aseptic pads held in 
position by a well-fitting diaper or broad T bandage. A large 
drainage-tube is passed well up into the rectum, its lower end 
extending outside of the dressings in order to convey the dis- 
charges and gases beyond the operative wound. This pro- 
cedure is applicable in the female, but it is somewhat difficult 



408 DISEASES OF ANUS, RECTUM, AND SIGMOID 

to avoid wounding the vagina, and there is always danger of 
infection from this organ during and after the operation. It 
does not appear to possess any advantages in women over 
the vaginal route. 

In incising the peritoneum, it is Turtle's practise to begin 
at the lowest portion of the anterior cul-de-sac and cut close 
to the intestine up to the mesorectum. From this point upward 




Fig. 137. — Perineal extirpation completed. U, tampon and drainage-tube in anus. (Tuttle.) 

he incises the peritoneal fold as close to the sacrum as possible ; 
first, because it avoids the danger of wounding the superior 
hemorrhoidal artery, and second, because it removes along 
with the growth all glandular enlargements in the meso- 
rectum. It can be well understood that the operation is not 
applicable to cases in which the tumor is isolated well above 
the rectum, and can be resected, leaving a healthy area of two 
inches or more between the anus and the growth. In other 



EXTIRPATION OF THE RECTUM 409 

words, where resection is feasible, the perineal route is not 
to be advised ; where amputation is necessary, this route should 
be employed. 

Sacral Method: Kraske's Operation. — This method con- 
sists in removing the coccyx and a portion of the lower end 
of the sacrum for the purpose of obtaining easier access to 
the upper portion of the rectum and lower sigmoid. Kraske 
was the first to carry out the suggestion and all subsequent 
suggestions involving the removal of the lower portion of 
the sacrum are modifications of his original method. 

I do not stop to review these various modifications, but 
give Tuttle's modification of Rehn and Rydgier's operation, 
with certain suggestions from myself. Our chief reason for 
adopting this method is because it involves injury to the sacral 
nerves and lateral sacral arteries of one side only ; it furnishes 
the most satisfactory access to the portion of the bowel to. be 
removed, and restores the bony floor of the pelvis and the 
attachment of the anal muscles. 

After the patient is prepared, as before suggested, the 
rectum should be packed with absorbing gauze, more espe- 
cially for the purpose of keeping the operator's fingers out 
of it. The patient is then placed in the left lateral position 
with the hips well elevated. An oblique incision is made from 
the level of the third foramen on the right side of the sacrum 
down to the tip of the coccyx, from which it is extended half 
way between this point and the posterior margin of the anus. 
After the incision reaches the cellular tissue posterior to the 
rectum, the latter is rapidly separated by the fingers from the 
sacrum, and the space thus formed together with the wound 
should be firmly packed with sterilized gauze (Fig. 138). A 
transverse incision is then made, at the level of the fourth 
sacral foramen; this should extend down to the bone, which 
must be rapidly cut through with a chisel in this line, after 
which the triangular flap is pulled clown to the left side, and 
held there (Fig. 139). At this point it is usually necessary 



410 DISEASES OF AXUS, RECTUM, AND SIGMOID 

to tie the right lateral and middle sacral arteries. If the first 
incision should have extended too far away from the sacrum, 
the right sciatic artery may be cut. 

Let the rectum now be isolated from the surrounding 
organs below the level of the resected sacrum so that a liga- 
ture can be thrown around it, or a long clamp applied to con- 
trol any bleeding from its walls (Fig. 140). If the growth 




Fig. 138. — Extirpation of the rectum by the sacral route 
operation. (Tuttle.) 



—first step in the bone-flap 



extends to or above the peritoneal attachment of the rectum, 
the peritoneal cavity must be opened at once, as it will be 
found much easier to dissect the rectum out by following the 
course of the peritoneal folds. These latter should be incised 
close to the rectum (Fig. 141), to avoid the danger of wound- 
ing the uterus and to facilitate dragging the rectum down. 
When the mesorectum is reached, the incision should be 
carried as far away from the rectum and as close to the sacrum 




Fig. 139. — Showing the rectum and adjoining parts with the principal vessels after the 
bone-flap has been turned down. 



EXTIRPATION OF THE RECTUM 411 

as possible, in order to avoid wounding the superior hemor- 
rhoidal artery and to remove all the sacral glands. The bowel 
should be loosened and drawn down until the healthy portion 
above the growth will easily reach either the healthy segment 
below it or the anus. The peritoneal' cavity should now be 
cleansed by wiping with dry sterilized gauze and then closed 
by sutures, attaching the membrane to the bowel. Let two 





Fig. 140. — Second step in bone-flap operation. R, rectum; N, neoplasm; LS, lateral rectal 
ligaments; 5, sacrum. (Tuttle.) 

intestinal clamps with the blades protected by rubber be applied 
to the healthy portion of the rectum about one and a half 
inches below the growth, so that when the bowel is excised the 
incision should pass only through healthy tissue. The dis- 
eased portion of the bowel is now cut across between the two 
clamps, the ends being carefully wiped, first with sterile gauze, 
then with alcohol; and covered with rubber protective tissue. 
The lower segment containing- the growth is then dissected 



412 DISEASES OF ANUS, RECTUM, AND SIGMOID 

from above downward in an almost bloodless manner, the 
superior hemorrhoidal vessel first having been clamped, much 
more easily removed in this direction than from below upward. 
If the neoplasm extends within one inch of the anus it will be 
necessary to remove the entire lower portion of the rectum, 
together with the mucous membrane from the anal canal (tak- 




Fig. 141. — Third step in bone-flap operation. P, opening in the peritoneum; V, seminal 
vesicle and bladder; N, neoplasm; R, rectum. (Tuttle.) 



ing care to leave the sphincter muscle) ; invaginate the upper 
end of the intestine through the anal canal, and suture it to the 
skin around the anal margin. 

If more than one inch of healthy bowel remains above the 
anus, the proximal and distal ends of the bowel should be 
united by an end-to-end anastomosis, using sutures to unite 
first the ends of the mucous layer, then the submucous with 
the muscular layer and the serous layer, if the bowel has been 



EXTIRPATION OF THE RECTUM 



413 



cut off above the attachment of the peritoneum (Fig. 142). 
Little if any tension should be employed in bringing the bowel 
down to the required position, as such a condition if allowed 
to exist will cause the sutures to cut out and the bowel to 
retract. After the ends of the bowel have been united, or 
the proximal end attached to the anal margin, a large silk 
anchor-suture is passed through the skin to one side of the 




Fig. 142. — Fifth step in bone-flap operation. The growth has been resected and the ends 
of the intestine have been sutured together. (Tuttle.) 



anal margin, and posterior to it up through the meso rectum, 
about three inches above the anus, and out again through 
the skin en the other side of the anus posteriorly; it is then 
tied. This is used to prevent too much tension on the sutures 
and retraction of the bowel. 

It was formerly thought that in certain cases it was impos- 
sible to get sufficient bowel clown from above to reach the anal 
margin. In such cases it was therefore recommended to attach 



414 DISEASES OF ANUS, RECTUM, AND SIGMOID 

the proximal end of the rectum at a higher level in the wound, 
thus forming what is known as a sacral anus (Fig. 143). 

I have one such case living on which I operated for sar- 
coma eleven years ago. It has since been demonstrated that 
sufficient bowel can be drawn down from above in almost 
every case, by cutting up the mesorectum sufficiently far, so 
that such a necessity need not now arise. All oozinsr is checked 




Fig. 143. — Sacral anus. 



by hot compresses, a drainage-tube is inserted on each side of 

the rectum near the points where the ends have been united, 
and brought out at the lower angle of the wound ; the bone-flap 
is fastened back in its original position by silkworm-gut 
sutures, which pass deeply through the skin and peritoneum on 
each side of the transverse incision. The lateral portion of the 
wound is closed by similar sutures drawn down to the level 
of the sacrococcygeal articulation: below this it is left open 



EXTIRPATION OF THE RECTUM 415 

for drainage-tubes. A large drainage-tube is carried up 
through the bowel beyond the line of intestinal sutures, and 
the wound covered with sterile gauze held in position by 
adhesive straps sufficiently tight to make firm pressure over the 
bone-flaps, and a T bandage made with a folded towel placed 
over this. Further pressure on the bone-flap is effected by 
placing the patient upon his back or right side, the head of 
the bed being slightly elevated in order to facilitate drainage, 
and the escape of blood should there be any hemorrhage, 
especially to prevent a concealed hemorrhage escaping upward 
into the peritoneal cavity. Usually there is considerable ooz- 
ing foi the first twenty- four hours following the operation, 
during which time the outside dressings should be changed. 

As soon as the patient's strength is sufficient he should be 
encouraged to get on his feet, in order to drain the parts more 
easily and also that the weight of the abdominal organs may 
press the pelvic floor backward against the sacrum, and thus 
hasten the filling in of this cavity. 

Let him be kept upon a concentrated liquid diet, and his 
bowels confined by opium, unless a preliminary artificial anus 
has been made, after which they are moved by an enema of 
oil and glycerin. 

The objections urged against this operation are, that the 
bone does not reunite and necrosis is likely to occur. This is 
answered by Tuttle and corroborated by the author's experi- 
ence. Neither of us have seen a single case of necrosis follow- 
ing the bone-flap operation, and in every case in which we have 
employed it the bone has reunited in fairly accurate position. 
My own objection is the amount of shock that is likely to fol- 
low this operation. 

Vaginal Method. — While extirpation of malignant growths 
of the rectum through the vagina was first done by Desguins 
(Annates de la socicte dc nied. d'Anvcrs, 1890) and by Norton 
(Trans. Clin. Soc, London, 1890), yet there was no clear and 
well-defined technic laid down for doing the operation until 
that suggested by Murphy, of Chicago. 



416 DISEASES OF ANUS, RECTUM, AND SIGMOID 

I had employed the vaginal route for excising malignant 
growths of the rectum in two cases, before Dr. Murphy pub- 
lished his technic. This route was selected by myself in each 
case because the vagina had become involved in the malignant 
growth ; at least it was firmly adherent to the rectum, although 
the vaginal wall had not broken down. In the first case, the 
operation was more satisfactorily done and the patient made 
a more rapid recovery (the wound uniting by first intention) 
than any case I have operated on before or since, yet there 
was a recurrence at the primary seat of the disease within 
three months, and although I did a second operation death 
from the disease occurred within a year. While the second 
case was not so satisfactory in its primary results, and the 
malignant growth had involved the vagina to a greater extent, 
yet I was careful to extend the incision well beyond the 
malignant growth. Nevertheless it returned in the primary 
seat of the disease within two months from the time of the 
operation, and the patient died from the disease within a year, 
notwithstanding the second operation. I have since learned 
that where the vagina has become involved in malignant 
growths of the rectum recurrences are very frequent, on 
account of the extensive chain of vascular and lymphatic 
vessels that exist between the two in the perineal body. This 
has certainly been my experience in such cases. 

Tuttle says that up to 1897 mos t operators confined this 
method to tumors in the middle and lower portions of the 
rectum, but with the development of the vaginal method in 
gynaecological operations it became more and more apparent 
that even the uppermost portion of the sigmoid flexure could 
be reached and extirpated by this route. The method is there- 
fore no longer limited to the rectum. Except in cases where 
the vaginal wall or uterus is involved, there is no great advan- 
tage in the vaginal route over the perineal and bone flap opera- 
tion described above. It requires more time, there is a greater 
loss of blood, and more danger of infection through uterine 
discharges and dripping of urine than in the sacral operation. 



EXTIRPATION OF THE RECTUM 417 

The technic of Murphy's operation, with modifications 
by Tuttle, is as follows : The patient is placed in the lithot- 
omy position with her hips slightly elevated. A semicircular 
incision is made between the anus and coccyx, and extend- 
ing into the retrorectal space. With the fingers or a dull 
instrument the cellular tissues and rectum are separated from 
the anterior surface of the sacrum and coccyx as high up 
as the wound extends. After this has been accomplished, the 
wound and sacral concavity are packed with iodoform gauze 
to control the oozing. The site of the tumor determines 
whether the peritoneum should be opened or not. The vagina 
is dilated with broad retractors, the cervix drawn down, and 
Douglas's cul-de-sac opened by a transverse incision just 
below the cervical juncture. The small intestines are pushed 
upward out of the way, the peritoneal cavity packed with 
large laparotomy sponges or pads, a careful count being 
kept of the number used. The rectovaginal septum is then 
divided by a vertical incision in the median line, extending 
from the first incision down to the margin O'f the anus, and 
including the external sphincter (Fig. 144). The vaginal 
wall is dissected from its attachments to the rectum, thus 
exposing this organ in its entire length and enabling one to 
examine it and drag down the sigmoid flexure almost at will 
(Fig. 145). When the bowel has been drawn down sufficiently 
for the healthy tissue above the growth to be attached below, 
close the peritoneal cavity by sutures before opening the bowel, 
which is now clamped with two intestinal clamps one inch and 
a half above the growth and cut across between the clamps, the 
cut ends being carefully wiped with dry gauze and alcohol. 
The distal ends of the bowel with the growth is now dissected 
out from above downward, as in Kraske's operation, which 
has been made much easier by the separation of the rectum 
from the sacrum in the first stages of this operation. The 
semicircular incision between the anus and coccyx also fur- 
nishes the most satisfactory drainage in case of leakage. Now 
clamp the bowel one and a half inches below the growth and 

27 



418 DISEASES OF ANUS, RECTUM, AND SIGMOID 

cut off; unite its proximal and distal ends with ten-day chro- 
micized cat-gut, and close the wound, drainage-tubes being 
introduced in the anococcygeal and vaginal wounds. 

While the vaginal route is a most useful addition to those 
previously described, it offers no decided advantage over them, 




Fig. 144. — Incision in vaginal extirpation. (Murphy.) 

except in those cases where the vaginal wall or the uterus are 
involved, or there is some special reason for not performing 
either of the others. 

Abdominal Method. — Where the malignant growth is lim- 
ited to the sigmoid and more especially to the movable portion 



EXTIRPATION OF THE RECTUM 



419 



of it, and can be brought outside of the abdominal wound, this 
method is the only one to be recommended. Let resection be 
made according to the recognized methods of intestinal sur- 
gery, doing either an end-to-end or a lateral anastomosis by 
suture. 




L 

Fig. i 






When the tumor is low down in the sigmoid it will be 
well to resort to a device recommended by Howard A. Kelly 
in 1895, °f resecting the upper portion of the rectum and a 
portion of the lower sigmoid, then invaginating the proximal 
end of the latter through a longitudinal slit in the anterior 



420 DISEASES OF ANUS, RECTUM, AND SIGMOID 

wall of the rectum in Douglas's cul-de-sac ; thus the peritoneal 
surface of the sigmoid will be held in contact with a compara- 
tively wide surface of the peritoneum covering the rectum 
(Fig. 146). The upper end of the resected rectum was 
invaginated and closed by Lembert sutures. 




Fig. 146. — Colorectostomy (Kelly) or invagination of colon through a slit in the anterior 
wall of the rectum. 



Combined Method. — In the majority of cases of malignant 
growths in the upper portion of the rectum or lower sigmoid, 
instead of resorting to the expedient recommended by Kelly 
in the previous paragraph, it would be easier to loosen the 
bowel from its higher attachments through an abdominal 



EXTIRPATION OF THE RECTUM 421 

incision, and subsequently complete the resection by the peri- 
neal or sacral routes. 

With regard to the combined method there are certain 
general directions which experience has proved necessary for 
successful results, some of which may be formulated in the 
following criticisms by Joseph C. Bloodgood, of the Johns 
Hopkins Hospital : 

" A careful study of the cases in the literature, I believe, 
will justify the following criticisms : 

" I. Colostomy has been performed too frequently as a 
primary operation. It is not indicated unless the patients are 
first seen in a condition of acute obstruction, or their condi- 
tion is so critical from chronic obstruction that a prolonged 
operation is contraindicated. If possible, the entire operation 
should be performed at one sitting. 2. It is unnecessary to 
ligate the vessels so far from the mesenteric border of the 
colon. Resection of the glands up to this point is not indi- 
cated. If they are involved, my experience demonstrates that 
the condition is hopeless for an ultimate cure. The disadvan- 
tage of ligating the vessels so far from the colon is that, after 
such a ligation, a more extensive resection of the large intes- 
tine is necessary to leave the bowel with proper circulation. 
3. Too much bowel below the tumor is removed. 

" If one restricts the resection of the large intestine above 
and below the growth to that necessary only for the complete 
removal of the disease, and ligates vessels as they are met with 
in the proper dissection of the mesentery, with its glands and 
the fat between the rectum and the sacrum, it will be possible, 
in a large number of cases, to restore the continuity of the 
bowel by an end-to-end anastomosis. 

" The pathological examination of a number of specimens 
and of the zone of mesenteric involvement which I have made 
apparently confirms the statement in the previous paragraphs. 
That is, in this somewhat restricted operation the new growth 
is given sufficient margin, at the same time the circulation of 



422 DISEASES OF ANUS, RECTUM, AND SIGMOID 

the remaining portion is not impaired, and in the majority 
of cases there may be restoration of continuity. 

" When the tumor involves the rectum below the promon- 
tory of the sacrum, at which position the posterior portion of 
the bowel has no peritoneal coat, it infiltrates quickly through 
the wall of the bowel into this tissue. The complete removal 
of all the tissue between the rectum and sacrum should never 
be restricted. There is every evidence to indicate that this is 
accomplished by the combined method better than by the sacral 
route alone." 

These criticisms we consider very conservative and agree 
with our own views and experience. They are in strong con- 
trast to those expressed by W. Ernest Miles (London Lancet, 
1908, Vol. II, page 1812), in which he says, "so far as he 
has been able to gather from the literature on the subject, 
the technic of previous operators seems to have failed in one 
important respect, namely, the complete eradication of the 
zone of upward spread of the cancer from the rectum, whereby 
the chance of recurrence of disease above the field of operation 
can be diminished, if not entirely obviated." In his own per- 
sonal experience of fifty-seven such perineal operations, recur- 
rence took place within periods ranging from six months to 
three years in fifty-four instances. 

For the purpose of ascertaining the cause of failure, he 
made post-mortem examinations of such of his patients as 
had died of carcinoma of the rectum, and found that the 
recurrence appeared in situations beyond the scope of removal 
from the perineum, namely, (a) the pelvic peritoneum, (b) 
the pelvic mesocolon, and (c) the lymph nodes situated over 
the bifurcation of the left common iliac artery. 

He compared these findings with the condition of those 
who had died from inoperable cancer of the rectum, and 
found that the disease invariably extended by continuity of 
tissue along the parietal attachment of the pelvic mesocolon, 
and in the adjacent parietal peritoneum for about one inch on 
either side of it, as far as the group of lymph nodes situated 



EXTIRPATION OF THE RECTUM 423 

over the bifurcation of the common iliac artery. In all cases 
thus examined, the infiltration of the parietal border of the 
pelvic mesocolon had caused shrinkage of the pelvic mesocolon 
itself, whereby the pelvic colon appeared to be bound down, 
a condition which readily explains the difficulty in obtaining a 
satisfactory spur when performing colostomy in an advanced 
case of cancer of the rectum. He therefore considers this 
area to constitute the zone of the upward spread of cancer 
of the rectum, and the removal to be just as imperative as 
the thorough clearing out of the axilla in cases of cancer of 
the breast, if freedom from recurrence is to be obtained. 

The appreciation of this important fact induced him, two 
years ago, to abandon the perineal method of excision of the 
rectum, and to substitute an abdominal method, comparable to 
those methods of performing abdominal hysterectomy, known 
as the Wertheim and the Kronig-Wertheim. I giive the 
summary of what he considers the essentials of his operation. 

He has formulated what he considers certain essentials 
w T hich must be strictly adhered to if satisfactory results are 
to be obtained, namely : ( i ) an abdominal anus is a necessity ; 
(2) the whole of the pelvic colon, with the exception of the 
part from which the colostomy is made, must be removed, 
because its blood-supply is contained in the zone of upward 
spread; (3) the whole of the pelvic mesocolon below the point 
where it crosses the common iliac artery, together with a 
strip of peritoneum at least an inch wide on either side of it, 
must be cleared away; (4) the group of lymph nodes situated 
over the bifurcation of the common iliac artery are in all 
instances to be removed; and lastly (5) the perineal portion 
of the operation should be carried out as widely as possible, so 
that the lateral arid downward zones of spread may be effec- 
tively extirpated. 

It will be seen then that Miles discards the perineal route 
entirely as an independent one, and does not restrict the com- 
bined method to those cases in which the growth is in the 
upper portion of the rectum or lower portion of the sigmoid, 



424 DISEASES OF ANUS, RECTUM, AND SIGMOID 

as generally done, but includes in his method of operating all 
cases of malignant growths that occur from the lower sig- 
moid down. His reasons given being the frequent recurrences 
after removal in his cases, fifty-four out of fifty-seven. 

Such has certainly not been my experience with malig- 
nant growths within the first five inches of the anal margin, 
as I can show. Out of eight cases operated upon, three 
patients are still alive, without recurrence after ten, eleven, 
and twelve years, and one after three years ; this shows a 
result of 50 per cent, of cures by the perineal and sacral 
routes, the last one of this group having exceeded the three- 
year limit. 

The Combined Operation. — The combined operation 
consists in loosening the bowel from its attachments within 
the abdomen, closing the peritoneal floor, and removing the 
growth either by the sacral or perineal method after the abdo- 
men is closed. The patient is prepared in the usual manner 
for an abdominal section, and placed in the Trendelenburg 
position ; the abdomen is opened and the small intestines packed 
off from the pelvic cavity; the sigmoid brought out of the 
abdominal wound. The peritoneum on each side of the meso- 
colon is divided and stripped back ; this exposes the fat and 
the vessels; the vessels are ligated, varying with the location 
of the growth, either the sigmoids, the inferior mesenteric, or 
the superior hemorrhoidal arteries (Fig. 147). The division 
of the peritoneum must be carried down on each side of the 
tumor some distance from it, over the sacrum to the bladder. 
The division of the peritoneum is not completed between the 
rectum and the bladder. With a piece of gauze the mesentery 
and the fat over the promontory of the sacrum are pushed 
forward, and the middle sacral artery exposed, doubly 
clamped, and ligated ; the sacrum being completely stripped of 
the tissue between it and the rectum. The patient is now placed 
in the extreme lithotomy position if the perineal route is 
taken for the removal of the growth, or in the extreme left 
lateral position if the Kraske method is to be used. The 



EXTIRPATION OF THE RECTUM 



425 



rectum is now separated from the surrounding tissues, as 
before recommended in either the perineal or Kraske method. . 
After this, if the tumor is a large one, and it can be done, 
cut the bowel off below the growth, between two ligatures, 




*r 



Fig. 147. — Extirpation of the rectum. (Tuttle.) Dissection showing peritoneum of 
the mesosigmoid (F) thrown back and the blood-vessels exposed and ligated so that when 
they are cut between the two ligatures the sigmoid can be swung down on the upper vessels 
as radii, thus permitting the removal of almost its entire length along with the rectum, at 
the same time bringing the cut edges of the peritoneum (FE) together so as to restore 
the mesosigmoid. A, superior hemorrhoidal artery; B, lower sigmoidal artery; C, left 
colonic artery; D, internal iliac artery; EF, cut edges of peritoneum; G, incision of per- 
itoneum separating bladder from rectum. 



and take it out through the abdominal wound. If the growth 
is small the bowel together with the growth must be drawn 
down and out through the perineal wound, and the peritoneal 
floor is repaired by sewing together the cut edges of the peri- 



426 DISEASES OF ANUS, RECTUM, AND SIGMOID 

toneum, after which the abdominal wound is closed. If the 
lower portion of the rectum to within two inches of the anal 
margin is not involved in the malignant growth, the rectum 
should be cut across an inch below and an inch above the 
growth, each incision to be made between two clamps, and 
the proximal and distal ends of the bowel united by an end-to- 
end anastomosis. If the growth approaches too near the anus 
for the anastomosis, then the mucous membrane should be 
dissected from the anal canal, care being taken to leave the 
sphincter* The bowel with the growth is then drawn down 
outside the sphincter, cut off one inch above the growth, and 
the edges of the bowel attached to the skin margin around the 
anus. In this latter procedure the perineal wound can be 
closed entirely, but if an end-to-end anastomosis has been 
done, then it is best to close it only partially, and drain from 
the point of the anastomosis. 



CHAPTER XVII 
WOUNDS, INJURIES, AND RUPTURE OF THE RECTUM 

Wounds and Injuries. — The position of the anus and 
rectum between the folds of the buttocks, as a rule, protects 
them from injury; notwithstanding there are a sufficient num- 
ber of injuries of this character to make the subject worth con- 
sideration. They may be conveniently arranged into con- 
tused, lacerated, punctured, or incised wounds. Contusions 
arise from falls on the buttocks, prolonged pressure from any 
cause, and undue manipulation in stretching the sphincter; 
lacerations, from sharp foreign bodies in the stools, excessive 
divulsion of the sphincter, and falling or sitting down upon 
sharp objects ; punctured wounds, from gun-shot or bayonet 
injuries, also from falling on sharp-pointed objects. Urethral 
sounds have sometimes been the cause of such accidents, but 
the greatest number have been occasioned by the improper 
use of syringe tips and rectal bougies, Tuttle records three 
cases that he has known in which the improper use of the 
Kelly tube caused perforation of the rectal wall, fecal extrava- 
sation, peritonitis, and death. Operations for stone in the 
bladder by perineal section or for prostatectomy have fre- 
quently resulted in injury to the rectum. 

Rupture of the Rectum. — This has occurred from the use 
of the colpeurynter in suprapubic cystotomy. Dragging upon 
the organ in efforts to break up attachments between it and 
pelvic growths by the use of force with the nozzle of a syringe, 
rectal bougies, in pelvic operations, penetrating and punctured 
wounds, and excessive pressure from the use of compressed 
air have all resulted in such injuries. Several cases have 
occurred during attempts to reduce rectal procidentia, and 
injury has also occurred from the introduction of the hand 
for diagnostic purposes. 

427 



428 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Prognosis. — The gravity of wounds and injuries to these 
parts depends largely upon the site, the tissues, and organs 
involved. Where the injury is confined to the anus and rectal 
walls, the wounds usually heal promptly under antiseptic pre- 
cautions, except in those cases where the puncture of the 
rectal wall has taken place within the anal opening, and with- 
out injury to it. The majority of such cases that have been 
reported have proved fatal, most likely due to improper drain- 
age through the closed anus. 

The results of gun-shot w T ounds of the rectum, according 
to the records of our Civil War and of the Franco-Prussian 
War, show a mortality of over 40 per cent. Pelvic cellulitis, 
septicaemia from infiltration, diffuse suppuration, and sec- 
ondary hemorrhage were the chief causes of death. 

Where the bladder is involved and the wound sufficiently 
large to allow fecal extravasation into that organ, the case 
is very grave. 

The seriousness of any injury to the rectum depends upon 
its height in the rectal wall, its extent, the form of the body 
making it, and the length of time elapsed between the injury 
and the institution of proper treatment. The principal factor 
in all these cases is the wounding of the peritoneum. Septic 
peritonitis ordinarily develops within twelve or fourteen hours 
when the peritoneum is involved, and in a certain number of 
cases, as shown by Watson, peritonitis has followed a pene- 
trating wound of the mucous wall of the rectum which has 
not extended to the peritoneum. 

Symptoms. — The symptoms of such injuries to the rectum 
itself speak for themselves ; the history, the wound, the loss of 
blood, the pain, and shock leave no doubt as to the character 
of the trouble. The extent of it and the involvement of other 
important parts, especially the peritoneum, require a more 
careful investigation of symptoms. In the latter case they 
are those of immediate traumatism, shock, hemorrhage, and 
pain. These vary greatly in different individuals, and one 
need not expect to find them all present and as pronounced in 



WOUNDS, INJURIES, AND RUPTURE 429 

every case, nor should the absence of all of them excuse the 
physician from making a most careful examination into the 
extent of all such injuries. The absence of external evidences 
of injury may be very deceiving. While there may be no 
blood discharged, the peritoneum and the upper cavity of 
the rectum may be filled with it. Tympanitis and abdominal 
pain may occur immediately after the accident, or they may 
be delayed for twenty-four hours, being preceded by a chill 
and followed by all the symptoms of septic peritonitis ; meteor- 
ism, an anxious expression of the face, vomiting, hiccough, 
and collapse may be present, soon to be followed by a fatal 
termination. Pain in the region of the pubis, dysuria, the 
presence of urine in the rectum, or of blood and faeces in the 
urine will indicate the involvement of the bladder in these 
injuries. Sometimes there is complete retention of urine, and 
the patient must be catheterized. In such cases one may find 
fecal material and blood in the urine, or no urine in the bladder 
at all, it having escaped into the rectum or peritoneal cavity; 
early and careful catheterization is therefore important. 

Aside from the subjective symptoms, an examination by 
the finger and instruments, especially the proctoscope, will 
indicate more clearly than anything else the size and extent 
of the injury. Do not be deceived, however, by the fact that 
there is no leakage of urine or faeces immediately after a 
puncture or gun-shot wound involving the bladder and rectum. 
The congestion and oedema following the injury may entirely 
close the tract of the missile temporarily, but it will soon 
reopen with subsidence of the oedema, or through sloughing 
of the tissues around the wound. A guarded prognosis is 
therefore necessary. 

The rapid escape of air from the rectum when using the 
pneumatic proctoscope, and inability to inflate it, should lead 
to a strong suspicion of perforation of the peritoneal cavity 
or bladder, even though there is no perforation seen or felt 
in the rectal wall. 



430 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Treatment. — Little trouble may be anticipated from minor 
wounds or injuries of the rectum and anus if the cardinal 
principles of drainage and disinfection are carried out prop- 
erly. Hemorrhage should be controlled by taking up the bleed- 
ing vessels if possible ; otherwise by packing, care being always 
taken to irrigate the rectum with hot antiseptic solution before 
the packing is done ; when the peritoneal cavity has been pene- 
trated, sponging should be substituted for irrigation. 

Perforations of the bladder through the rectal wall often 
heal spontaneously; therefore, in those cases in which there 
is no peritoneal involvement, early operative interference is 
not advisable. The bladder may be drained by a soft catheter, 
and the rectum kept as free from fecal material as possible by 
stretching the sphincter and frequent irrigations. If, after 
a reasonable time, the opening between the two fails to heal, 
and the condition develops into a rectovesical or a recto- 
urethral fistula, then it should be closed by methods heretofore 
recommended. If fistulse, abscesses, or ulceration follow these 
injuries, they should be treated as recommended elsewhere 
in this section. 

Wherever there is good reason to believe that the peri- 
toneal cavity has been opened by a wound in the rectum, an 
exploratory laparotomy should be done at once, and the site, 
course and extent of the injury determined. If there should 
be much extravasation of blood and fecal material into the 
peritoneal cavity, wash it out thoroughly with large douches 
of normal saline solution. If, however, there is only a very 
small quantity that has escaped, wipe off the parts that have 
been soiled with pledgets of gauze that have been soaked in a 
mild solution of bichloride of mercury. It is better to clean 
out Douglas's cul-de-sac by this method than by general irri- 
gation, for by the latter one may distribute septic germs 
throughout the cavity. If septic peritonitis has begun Quenu 
advises prolonged lavage with normal saline solution at 
40 C. Where the wound in the rectum, or sigmoid, is within 
reach through the abdominal wound, it should be sutured ; this 



WOUNDS, INJURIES, AND RUPTURE 431 

cannot be conveniently done if the wound is low down in 
Douglas's pouch, although the operator may be assisted very 
much by the use of the colpeurynter in the rectum. Make 
no attempts to suture, however, until the pelvic cavity has 
been thoroughly cleansed, and the location of the wound 
packed off with sterile gauze. Whenever there has been 
extravasation in these cases, drain always with gauze running 
from the site of the intestinal injury to the lower part of the 
abdominal wound. 

The treatment of rupture of the rectum calls for imme- 
diate laparotomy and suturing of the wound. 



CHAPTER XVIII 
FOREIGN BODIES IN THE RECTUM AND SIGMOID 

Foreign bodies are frequently met with in this part of 
the intestinal tract, and there are three methods by which they 
reach there : first, by being swallowed ; second, by being devel- 
oped in some portion of the intestinal tract; third, by being 
introduced through the anus. 

Medical literature abounds with instances of foreign bodies 
of the most varied and marvellous character that have been 
swallowed and subsequently found in these cavities, such as 
chicken- or fish-bones, the outer hull of an apple-seed, false 
teeth, tin tags, etc., etc. 

There are certain conditions that predispose to the forma- 
tion of foreign bodies in the intestinal canal. These depend 
upon the altered or deficient secretions from the intestinal 
canal, the liver, or the pancreas. Enteroliths have their origin 
in small bodies that have been swallowed and around which 
the lime salts incrustate. Those who live in limestone regions 
and drink the hard alkaline water are especially inclined to 
the formation of these calcareous masses in the intestine. 

As a predisposing cause may be mentioned constrictions 
in the sigmoid or rectum, growths, hypertrophy of Houston's 
valves, paralysis of any portion of the large intestine, diver- 
ticula, displacements, or adhesions of the sigmoid or colon, 
hypertrophy, and spasm of the external sphincter. 

For various reasons foreign bodies are frequently intro- 
duced into the rectum, and while it is always with the knowl- 
edge of the patients, the purposes for which they are intro- 
duced are of such a nature that they will not admit it until 
forced to do so by pain and distress. 

In a certain number of cases foreign bodies are introduced 
into the rectum by ignorant people for the relief of certain 
432 



FOREIGN BODIES 4>33 

conditions or symptoms, as for constipation, or its reverse 
condition, diarrhoea. 

Again, the rectum has been, for a long time, made use of 
by thieves and criminals for the purpose of concealing stolen 
articles and instruments for crime. 

Foreign bodies have also found their way into the rectum 
by accidents, as by falling on pointed sticks, or on the palings 
of fences, which after penetrating the rectum are broken off 
and left there. 

Under this heading may also be mentioned those distress- 
ing cases in which foreign bodies have been introduced for 
the purpose of exciting passion in depraved individuals, where 
the object has slipped from their grasp and passed up into the 
rectum. 

The length of time that a foreign body that has been 
swallowed will take to pass from the stomach to the rectum 
varies from twelve hours to several months. 

Some remarkable cases have occurred in which large 
bodies that have been introduced into the rectum have worked 
their way upward until they were beyond the reach of the hand 
or of instruments used for their removal. 

Symptoms. — The symptoms will depend very much upon 
the size and shape of the body; if smooth, round, and not very 
large, it may give rise to very few symptoms ; but if large and 
irregular, with sharp edges or points, it will cause pain and 
tenesmus. Again, the pain and tenesmus will depend upon the 
location of the foreign body, being more pronounced when it 
is low down in the rectum. If the mucous membrane or the 
walls of the rectum have been penetrated, the pain will be more 
or less constant, especially if the foreign body is grasped by 
the sphincter, in which instance the case will likely present the 
symptoms of fissure in ano. The irritation from the foreign 
body is likely to bring on numerous stools, which, in the 
absence of any direct history concerning the foreign body, 
may mislead the physician. Genito-urinary symptoms are a 
very frequent complication of foreign bodies in the rectum. 



434 DISEASES OF ANUS, RECTUM, AND SIGMOID 

When the body has remained for some time in the intestine 
and produced much irritation, grave constitutional symptoms, 
with high temperature, may supervene. 

In certain cases where the foreign body is very large, a 
bulging of the perineum may be felt and seen. 

Diagnosis. — The only reliable means of diagnosis in these 
cases is the educated touch and the proctoscope, the latter to 
be used only w T hen the body has passed up beyond the reach of 
the finger ; then it can be used, not only as a means for making 
the diagnosis, but through which the foreign body may be 
grasped with forceps and pulled down. In those cases in 
which the foreign body is small and is arrested in one of the 
crypts of Morgagni, a single-bladed speculum, such as the 
one I designed, would be of special advantage in making the 
diagnosis, reflected light being used to illuminate the field of 
inspection. 

Complications. — In the spontaneous expulsion of foreign 
bodies, wounds and tears are likely to result; the retention of 
the foreign body in the rectum for some time may result in 
erosions or ulcerations of the surfaces ; in thickening of the 
rectal wall ; in invagination or prolapse of the rectum. These 
conditions may call for subsequent attention and treatment. 

With the history and symptoms of a foreign body in the 
rectum, it may yet be impossible to demonstrate its presence, 
either by digital examination or the proctoscope. This may be 
due to the fact that the foreign body has been dropped into 
a diverticulum, or has penetrated the rectal wall and passed into 
the surrounding tissues. 

Prognosis. — While most of these cases end favorably, 
quite a number have died from infection, hemorrhage, or 
peritonitis. 

Treatment. — Difficulties attending the extraction of for- 
eign bodies from the rectum may well be appreciated, when it 
is remembered that they are generally introduced with the 
conical end upward, and have behind them a tight and fre- 
quently an irritable and painful sphincter. 



FOREIGN BODIES 435 

Where the body is soft in character it may be grasped 
with forceps, but when hard in texture and smooth it will 
tax every ingenuity of the operator to remove it, esoecially 
as he has to keep constantly in mind that much pressure from 
below is likely to push it farther up the bowel, or if the upper 
end of the object is pointed much manipulation and pressure 
on the abdomen may cause it to perforate the intestine and 
bring on fatal peritonitis. 

Generally it will be necessary to anaesthetize the patient 
and dilate the sphincter before any attempt at removal is made. 
Then the bowel should be well irrigated with an antiseptic 
solution to remove any cause of infection, and this should be 
followed by an injection of sweet or cotton-seed oil, to lubri- 
cate the parts well. If the calibre of the anus is found too 
small for the removal of the foreign body, it will be advisable 
to split the anus and rectum backward towards the coccyx 
sufficiently to allow its removal. The necessity for this pro- 
cedure is the result of the congestion and oedema which has 
followed the pressure of the foreign body. When the lower 
end of the foreign body is rough and serrated it will be neces- 
sary to protect it with gauze to prevent the serrations from 
catching in the mucous surface. 

When the foreign body is composed of soft metal, such as 
hair-pins or safety-pins, they may be cut with forceps. 

Where the object is of glass or china, the small placental 
forceps may be used to extract it; they should be wrapped 
with gauze, if there is danger of the glass breaking, to prevent 
the pieces of glass from wounding the mucous membrane. 

Always after removal of a foreign body from the rectum 
this organ should be thoroughly irrigated with an antiseptic 
solution, such as boric acid or 10 per cent, peroxide of hydro- 
gen. If the bowels have not been moved, a mild cathartic, such 
as castor oil or comp. licorice powder must be given at once 
to remove any undue accumulation of fecal matter. As soon 
as this result has been accomplished an opiate should be given 



436 DISEASES OF ANUS, RECTUM, AND SIGMOID 

to quiet peristaltic action. Irrigations with very cold or very 
hot water, and pressure by packing, are the best means to 
control hemorrhage. 

Removal by Coeliotomy. — When large bodies have passed 
upward beyond reach, or have been arrested in their passage 
from above downwards in the upper part of the sigmoid 
flexure, it may be advisable to open the abdominal cavity at 
once, make a longitudinal incision in the gut, and remove the 
foreign body through this aperture. If the bowel is healthy 
the incision in it should be closed at once, and dropped back 
into the abdominal cavity ; if gangrenous, then all the diseased 
part must be drawn outside, and the healthy edges of the 
bowel stitched to the abdominal wound. The diseased portion 
of the bowel may be cut off, or if it resumes its normal con- 
dition it can be closed and restored to the abdominal cavity 
at a later date. 

The incision for such an operation should always be made 
at the left side and in the line with the rectus muscle. 

When attempting to remove the foreign body through an 
abdominal opening, the portion of the intestine in which the 
foreign body is located should be drawn outside of the abdo- 
men if possible and the abdominal wound packed with gauze 
before the intestine is opened. Sometimes on account of its 
short mesentery it will be impossible to do this completely. 

If the foreign body has escaped from the intestine into 
the abdominal cavity, laparotomy should be performed, the 
foreign body removed, and the rent in the bowel, through 
which the foreign body . passed into the abdominal cavity, 
should be sewed up, after which the abdominal cavity should 
be thoroughly washed out with sterile water and closed. 

G. W. Combs, of Indianapolis, Indiana (Journal of the 
American Medical Association, October 23, 1909), reports a 
very interesting case : 

History. — J. L. was admitted to the City Hospital, June, 
1909. He had been drinking heavily for four days, and one 
evening went to a wood beside a railroad, where he lay on 



FOREIGN BODIES 437 

the ground, falling asleep and not waking until morning. He 
found it impossible to empty the bowel on account of an 
obstruction and pain. There was in the rectum a beer glass 
about seven inches in circumference at the larger end, a little 
more than four inches in length and conically shaped. He 
applied for help to a physician who attempted to remove the 
glass, without divulsion, with forceps. The attempt failed 
and the glass was broken. 

He was admitted to the hospital about 3 p.m. and the glass 
was removed about 5 p.m. The smaller end had been intro- 
duced first, and when seen at 5 p.m. was resting up about the 
promontory, the larger end, a segment of which had been 
broken out in the effort at removal just mentioned, was 
imbedded in the hollow of the sacrum, the cutting edges being 
buried in the soft tissues. 

Operation. — The oedema and swelling, and the contraction 
of the levators and sphincters from traumatism were such that 
thorough divulsion was insufficient for removal. The muscles 
were divided in the median line posteriorly, sufficiently to 
effect the removal of the glass, and on account of the extensive 
swelling and oedema, and the presence of an ichorous, bad 
smelling discharge, the wound was not stitched but left to 
heal by granulation, as in posterior proctotomy for stricture. 
When the patient was discharged he had perfect control over 
his fecal discharges. 



CHAPTER XIX 

HYSTERICAL OR IRRITABLE RECTUM; NEURALGIA OF THE 
RECTUM; OBSCURE DISEASES OF THE RECTUM 

The condition ordinarily described as hysteria has of late 
years received much more attention and consideration from 
physicians than formerly and has generally been found to be 
associated with some diseases of the ovaries or uterus, although 
in many cases the etiology is still shrouded in darkness. In 
most cases of hysterical rectum, however, if one searches long 
and carefully enough, he will generally find some local or 
reflex cause to account for the symptoms. 

Dr. William Goodell has stated that few muscles of the 
body are exempt from attacks of hysteria, and those that are 
most liable to be so attacked are the circular muscles. In 
most of the cases so affected, according to this author, one 
finds symptoms of nervous prostration, backaches, and ner- 
vousness, but the chief symptom is referred to the rectum. 
So exaggerated may this symptom be that it masks all the 
others and leads one to believe that he is dealing with some 
pathological lesion of this organ. 

In some cases the symptoms closely resemble those of an 
anal fissure ; in others the pain is higher up than the sphincter 
muscle, with a tendency to return periodically; and in others 
still there is a throbbing, pulsating pain that occurs before 
and during defecation, but disappears after the bowels have 
been emptied. In addition to those associated with actual 
pain, there are others described by Goodell in which the 
sphincter muscle is persistently and powerfully contracted 
without any appreciable cause to account for it. 

In some cases defecation is followed by great exhaustion, 
whether the stool is fluid or solid. In others the rectum is so 

438 



HYSTERICAL OR IRRITABLE RECTUM 439 

sensitive and irritable that the least pressure from the faeces 
or from the nozzle of the syringe will bring on spasm and 
actual agony. 

The least excitement from social, business, or other causes 
will sometimes bring on either a relaxation of the sphincters 
and inability to control the movements of the bowels, or a 
spasm of those muscles which unfits the patient for society 
or business. 

Notwithstanding- the practical denial by Dr. Mathews of 
the existence of any such symptoms without a corresponding 
pathological lesion, yet after giving full credit to reflexes from 
other organs, especially the reproductive, there still exists a 
certain number in which it is impossible to find a pathological 
cause for the erratic symptoms ; nevertheless the search for 
the cause should be most careful and painstaking in every 
instance. The lesions to be looked for in such cases are small 
fissures; scar tissue from sores that have healed; hypertro- 
phied papilla which have prolapsed and been caught in the 
grasp of the sphincter; small polypi; inflamed hemorrhoids; 
small fecal concretions. Foreign bodies in the crypts are very 
common causes, yet likely to be overlooked. The pressure of 
a fecal mass during periods of constipation may produce irri- 
tability of the rectum, congestion, hypertrophy, and spasm of 
the sphincter, and along with these changes there is an increase 
in the fibrous elements which constricts the ends of the nerves, 
producing neuralgia. 

Reflex Irritations. — The most familiar of these are 
those that arise from lesions in the genito-urinary organs. It 
is well known to all surgeons, and even general practitioners, 
how the rectum and the genito-urinary organs react on each 
other, and how a disease in one may find its most prominent 
expression in some reflected symptom in the other. Where 
no organic lesion can be found to account for the symptoms 
in the rectum, a systematic examination of the other organs 
of the pelvis should be made. 



440 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Frequently, however, nothing will be found in any of 
these organs to account for the neuralgic pains or irregular 
symptoms which occur. In such cases turn your attention to 
the nervous system, especially the spinal cord. Spasm and 
pain in the rectum are frequent symptoms in the beginning 
of locomotor ataxia. In many cases these pains occur in 
the rectum before they do in the legs and in the course of the 
sciatic nerve. 

Allingham has noticed the same to occur in certain cases 
of impaction of faeces in the rectum or sigmoid ; symptoms of 
insanity with delusions have appeared, which have disappeared 
when the impaction has been relieved. 

Not infrequently gout and rheumatism have been known 
to produce these pains. In such cases large doses of the 
salicylates generally give prompt relief, as do also full doses 
of colchicum in cases due to gout. 

Loss of Normal Sensibility. — In this condition the sen- 
sibility of the rectum is below par, and response to normal 
stimuli is wanting. This condition may come on suddenly 
after the bowels have been moving regularly for weeks, when, 
following a period of excitement or nervous strain, there 
appears a diarrhoea with involuntary passages of faeces. The 
patient will have no warning of such an accident until the 
actual escape of fecal matter and is likely to become depressed 
and hypochondriacal. Such a condition may be entirely inde- 
pendent of any previous operative procedure on the rectum, 
and in those cases where it is entirely independent a satisfac- 
tory explanation may be looked for and found in defective 
sphincteric control by the spinal centre, which in turn is the 
result of a defective link somewhere in that special reflex arch. 

Treatment. — The line of treatment to be adopted will 
depend upon the exciting cause, if it can be ascertained or sus- 
pected. Removal of it or its treatment is always called for. 
Where there is hypertrophy with spasm of the sphincter it 
should be dilated or incised ; hemorrhoids, or hypertrophied 
papillae should be removed ; ulcerations should be treated with 



HYSTERICAL OR IRRITABLE RECTUM 441 

appropriate applications; congestions by irrigations of cold 
water; and defective nerve control by the internal use of 
strychnia, cold packs to the lumbar and sacral regions of the 
spine, with the daily use of the faradic current. 

When there is a prolapsed ovary, a retroverted or pro- 
lapsed uterus, an enlarged prostate, stricture, or any pelvic 
lesion that may act as a reflex in producing the rectal symp- 
toms, they should receive prompt and appropriate treatment. 
There still remain a certain number of cases in which no 
organic disease can be found in the rectum, pelvic organs, 
spinal cord, or brain, as causative and most of these cases 
are the victims of anaemia or autotoxaemia and nervous exhaus- 
tion. The treatment therefore may safely consist in rest, 
forced feeding, tonics, and change of environment. 



CHAPTER XX 
PATHOLOGICAL LESIONS OF THE COCCYX 

The coccyx, being one of the main stays for the support 
of the rectum, always involves the latter to a greater or less 
extent when diseased, which is my excuse for alluding to 
diseases affecting it in a work on the rectum and anus. I will, 
however, give a detailed account of the subject. 

The following is a list of its affections which concern us 
here: malformations of the coccyx; fractures and dislocations 
of the coccyx; sacrococcygeal tumors and cysts; coccygodynia. 

Malformations. — Not infrequently we have a congenital 
deformity of the coccyx, either with a lateral, anterior, or 
posterior deviation. In cases of anterior curvature the rectum 
may be caught between the end of the coccyx and fecal con- 
cretions, causing considerable irritation or ulceration. In 
cases of posterior curvature the tension of the skin over the 
curved coccyx may result in ulceration. These conditions 
may pass unnoticed unless the deflection is sufficient to inter- 
fere with the surrounding tissues, when it will be readily 
recognized by the attending pain and irritation, which should 
lead to the necessary examination which will reveal the cause 
of trouble. When there is ulceration in the rectum from an 
acute anterior deflection there will be discharges of pus and 
blood from the anus. 

Treatment. — This malformation is best corrected by 
removing the coccyx, the technic of which will be subsequently 
given under the head of coccygodynia. 

Fractures and Dislocations of the Coccyx. — From its 
dependent position the coccyx is very subject to fractures or 
dislocations from violent falls upon the buttocks; this con- 
dition is readily recognized. The pain and discomfort, espe- 
cially upon flexing the body upon the hips, will direct the 

442 



LESIONS OF THE COCCYX 443 

attention of the physician to the part, which, taken in connec- 
tion with the history of a fall, should suggest an immediate 
examination. This is best done by introducing the index finger 
into the rectum and with the thumb over the coccyx, when 
either crepitation or a very movable coccyx will be recog- 
nized. It should be borne in mind that there may be a con- 
genital movable coccyx. In either case, however, the treat- 
ment would be the same. 

Treatment. — On account of the attachment to the coccyx 
of ligaments and muscles, the slightest contraction or extension 
of which makes it impossible to fix the bones after they have 
once been separated from their adjoining segments or the 
sacrum, little can be clone by palliative measures to relieve 
the discomfort of the patient, except by confining him to the 
recumbent position and making his evacuations as soft and 
easy as possible. Here, as in the preceding condition, imme- 
diate and complete extirpation affords the quickest and best 
results. 

Sacrococcygeal Tumors and Cysts. — The coccygeal body 
(Luschka's gland) may become inflamed and swollen, or it 
may undergo degeneration and result in the formation of a 
cyst or abscess ; this can be readily recognized by the swollen 
condition on the anterior surface of the coccyx and the ten- 
derness experienced by pressure on passing the right index 
finger in the rectum and the thumb over the coccyx. 

When the coccygeal body has become inflamed and painful 
it will be best to apply an ice pack in the early stages of the 
trouble, but later hot applications and suppositories will be 
best. When these remedies fail the coccygeal body and the 
coccyx may both be extirpated at the same time. 

Braune was the first to classify sacrococcygeal tumors, in 
1862, and to recommend the different methods for their treat- 
ment. Since that time Holmes has suggested the following 
classification: (a) tumors assuming the forms of supernume- 
rary limbs, the result of double fetation; (b) tumors with 
fibrofatty (lipomata) constituents where congenital duration 



444 DISEASES OF ANUS, RECTUM, AND SIGMOID 

is not apparent; (c) congenital tumors which enter the pelvis, 
not of fetal origin. 

These tumors may be attached by a broad base or narrow 
pedicle, and vary in wide extremes in their contents and size. 
They may be globular, oblong, and irregular in shape; solid, 
semisolid, or soft. 

Most of these are congenital, with the exception of the 
lipomata, and are rather rare except the dermatoid cysts, 
described elsewhere, under the head of Benign Tumors. 
These are readily recognized when attached to the posterior 
surface of the sacrum or coccyx, but when from the anterior 
surface they may not be observed until sufficiently large to 
interfere with the functions of the rectum by pushing it for- 
ward. In exceptional cases they may have attained such 
size as to dislocate the coccyx and lower part of the sacrum 
backward, and to cause prolapse of the rectum and eversion 
of the anus. 

Constipation, of course, is very marked in these extreme 
cases, and is probably one of the first symptoms to call atten- 
tion to those growing from the anterior surface of the coccyx 
before the tumor has become very large. These tumors break 
down and form abscesses which result in fistula, or the fistula 
may be the result of a previous necrosis of the coccygeal or 
sacral segments. In the congenital tumors, as spina bifida, 
the cavity of the tumor communicates with the spinal cord. 

A digital examination of the rectum is always necessary 
in those tumors that grow from the anterior surface of the 
bone to ascertain its attachments, and for the purpose of 
palpation. 

Treatment. — These tumors should be dealt with by radical 
measures only, some of which are as follows: (a) tapping, 
(&) partial resection and ligature, (c) complete extirpation. 

Tapping. — Only resort to this as a palliative measure, as 
the tumor refills with fluid A r ery soon, and, when done, the 
fluid should be withdrawn slowly so as to avoid the risk of 
convulsions. 



LESIONS OF THE COCCYX 445 

Partial Resection. — This is only done as a result of 
failure in the attempt at total extirpation, where the attach- 
ment has been so extensive and deep as to make extirpation 
impracticable. In this partial resection let as much as possible 
of the tumor be ligated and removed. 

Complete Extirpation. — This is the most desirable 
method of getting rid of sacrococcygeal tumors, unless they 
are connected with the spinal canal; when such is the case it 
is best to let them alone. 

The technic of the operation is as follows : A free incision 
is made over the tumor and the latter carefully dissected out 
from its neighboring structures with the ringer or blunt scis- 
sors. When the tumor is attached by a pedicle it should be 
traced upward to its origin, where it is extirpated completely. 
When cystic in character every precaution should be taken 
not to puncture the cyst wall. If the peritoneum has to be 
opened, let it be subsequently closed with cat-gut, the external 
incision likewise closed with the same, unless there is great 
tension, when silk sutures may be used. 

When there are supernumerary limbs attached to the 
tumor they should be amputated or resected, as circumstances 
demand. Where necrosis occurs, from whatever cause, remove 
the dead bone, curette the surrounding parts, and leave the 
wound to heal by granulation. 

Coccygodynia. — Coccygodynia is a persistent pain referred 
to the region of the coccyx ; it is confined almost exclusively 
to women who have given birth to children. The pain is due 
to rupture or stretching of the ligaments surrounding the 
coccyx, or fracture or dislocation of that bone. 

The condition was first described by Dr. J. C. Nott, of 
Alabama, in 1844 (" Extirpation of Os Coccyx for Neural- 
gia," New Orleans Med. Jour., 1844-5).* 

* Skene, in his Diseases of Women, says : " This was first described 
by Dr. Nott in the North American Journal, May, 1844. but it attracted 
little attention until 1861, when Sir James Y. Simpson revived the subject 
and gave it the name of coccygodynia." 



446 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Etiology and Pathology. — While coccygodynia occurs 

most frequently in women who have borne children, in whom 
it is due to injury of the bone or its ligaments during child- 
birth, yet it may follow injuries to the parts from other causes, 
in males as well as females, as from falls on the buttocks, or 
from blows over the region of the coccyx. The coccyx may 
also be the seat of rheumatism or neuralgia, or the coccygo- 
dynia may result from displacement of the coccyx by coccygeal 
tumors, or from inflammation of the coccygeal body. 

Symptoms. — It is characterized by a very annoying and 
persistent pain in the region of the coccyx while in the erect 
position, and for some time after lying' down, comparable 
to a dull toothache, which by its persistency makes the patient 
very nervous. The pain is very much increased by exercise, 
especially when leaning the body forward, by the act of defeca- 
tion, or by any sudden movement that affects the mobility of 
the coccyx. 

Diagnosis. — The diagnosis is very readily made from 
the history and from a digital examination with the index 
finger in the rectum and the thumb over the coccyx. The 
slightest movement of the coccyx by the thumb and finger will 
increase the pain very much, 'there will be added exquisite 
tenderness, there may or may not be mobility of the parts 
according to the amount of stretching the ligaments may have 
sustained, or whether or not there has been any dislocation. 
The absence of any swelling would differentiate it from a 
tumor or inflammation of the coccygeal body. In some cases 
the pain may be referred to some neighboring organ, but the 
history of a fall, or having borne children, and an increase of 
pain by a movement of the coccyx, will enable us to make 
the proper diagnosis. 

Treatment. — Palliative measures are generally of little 
avail, although occasionally they may afford permanent relief. 
Of these measures, rest is decidedly the most important; the 
next is the avoidance of all means likely to produce spasm of 



LESIONS OF THE COCCYX 447 

the coccygeal muscle, and the use of such local measures cal- 
culated to relieve such spasms; of the first, the avoidance of 
constipation, or any sudden movement affecting the coccyx; 
of the second, hot applications are most soothing and effectual. 
In some chronic cases brushing the parts over with the cautery 
at a dull red heat is very efficacious. When these palliative 
means fail, surgical methods should be resorted to. 

Surgical Methods. — One of two methods may be 
adopted for the relief of this trouble; first, small tenotomy, 
or total excision. 

Tenotomy. — This operation was first performed by Prof. 
J. Y. Simpson, and the results following were very satisfac- 
tory, but of late the operation seems to have fallen into disuse. 
The technic is as follows : A tenotomy knife is introduced 
through the skin near the tip of the coccyx and passed upward 
directly over the posterior surface of the bone, which is now 
freed from all attachments to the adjoining parts. The tenot- 
omy knife is now turned at an acute angle, first on one side, 
then on the other, when all lateral attachments are severed, 
and the incision is extended beyond the tips of the bone from 
one side to the other, thus severing the bone from all its 
attachments, except at its base with the sacrum. The bone is 
thus relieved from all movements by the muscles, and perfect 
rest is secured. While this method may relieve a certain 
number of cases, it is not likely to answer where the bone is 
the seat of disease, so I prefer excision as being more certain 
to relieve the difficulty, and by the method suggested by 
Samuel G. Gant it is quite as readily and easily performed. 

Total Excision. — The former methods of excising the 
coccyx were quite tedious and rather difficult, and the practise 
of leaving a drain in the wound delayed healing considerably. 
The operation devised by Gant simplifies the operation very 
much and gives most satisfactory results, and is the best that 
has been recommended. He has devised a pair of scissors 
especially constructed for this operation (Fig. 148), which are 



448 DISEASES OF ANUS, RECTUM, AND SIGMOID 

very strong and blunt at the point, and the only additional 
instruments needed are a large curved needle, a needle-holder, 
and plain cat-gut sutures. Here is his technic : 




Fig. 149.- — Excision of the coccyx. 

i. The skin and deeper tissues over the end of the coccyx 
are grasped with the thumb and index finger, so as to make a 
fold at right angles to the latter. 

2. With one stroke of the scissors, cut through these struc- 
tures down to the bone, making an incision one inch long, 
parallel with the coccyx. 



LESIONS OF THE COCCYX 449 

3. Free and lift the end of the coccyx upward with the 
left index finger, and by rapid cuts detach all the tissues first 
from one side then from the other, and finally from the end 
of the bone. 

4. Without changing the position of the finger, place the 
scissors at right angles to the coccyx (Fig. 149), and disarticu- 
late or divide it, as the case requires. 

5. Close the wound with two or three interrupted cat-gut 
sutures, and dress it with sterile gauze held in place by adhe- 
sive straps. 

The advantages claimed for this method are, that it is 
bloodless, painless, and can be done with great rapidity. 



29 



CHAPTER XXI 

CONGENITAL IDIOPATHIC DILATATION OF THE COLON 

(Hirschsprung's disease) 

The frequency with which the sigmoid portion of the 
colon is involved in these cases of congenital dilatation, 
together with the fact that obstinate constipation is one of its 
most pronounced symptoms, is my reason for considering this 
subject in a Treatise of the Rectum, etc. 

J. M. T. Finney, of the Johns Hopkins Hospital, has given 
the most complete resume of the subject that we have been 
able to find, in an article which appeared in Surgery, Gyne- 
cology and Obstetrics, Vol. VI, page 624, 1908. To him I am 
indebted for the full report on this subject. " While Hirsch- 
sprung was the first to bring this condition to the general 
attention of the profession in the year 1886 at the meeting of 
the Berlin Congress for Children's Diseases, yet it had been 
recognized and cases reported by a number of observers. The 
earliest reported cases to be found in the literature are those 
of Parry in 1825, and Eillard in 1829. Parry's case was a 
male adult, who had suffered from digestive disturbances for 
years: Autopsy showed an enormously distended colon, con- 
taining an immense quantity of faeces. No obstruction could 
be found anywhere in the alimentary canal. Billard, accord- 
ing to Lowenstein, in 1829 reported the autopsy findings of 
a six days' old boy, the lower part of whose small intestine, 
together with the whole colon, was thickened and sclerosed. 

" Von Ammon, in 1842, described a dilatation of the large 
intestine and rectum in a child shortly after birth, and recorded 
another observation in a foetus about the seventh month. It 
is a curious fact that these observations, having such an 
important bearing on the etiology of the disease, should have 
been noticed so early and that so few similar conditions have 

450 



DILATATION OF THE COLON 451 

since been reported." Then come the reports of Oulmont, 
1843; Banks, Bunfer, and Favalli, 1846; Little and Galloway, 
1850; Gay, in 1854. 

Henock, in 1861, gives a description of a fairly typical case 
in a young boy. In 1867 the ^ rst case from this country was 
reported by Lewitt, of Chicago. This was followed three 
years later (1870) by Jacobi, who reported a doubtful case of 
abdominal loop formation with fatal kinking of the intestine. 
No less than two hundred and six communications on this 
subject have been found by W. A. Fisher, who rendered 
Finney such valuable assistance in the preparation of this 
paper. 

Finney states that his paper represents a review of their 
knowledge of the subject with a complete list of authors and 
their publications to January 1, 1908. 

Terms and Synonyms. — This condition is designated by 
several synonyms, some of which depend upon the etiological 
conception of the disease, while others have to do only with 
the names of individuals. In the former class belong the 
terms "Megacolon Congenitum " (Mya) and "Congenital 
Idiopathic Dilatation of the Colon " (Hirschsprung). In the 
latter belong Hirschsprung's Disease, or Mya's Disease. The 
term " Giant Colon " has also been used by some authors 
(Formad, Osier, Futcher, etc.). 

The term " Congenital Idiopathic Dilatation of the Colon " 
is the one generally used in this country. 

There is abundant evidence that in the majority of cases 
the disease has its origin in utero, also that the affection is 
essentially a dilatation and hypertrophy and has in nearly all 
cases to do with the colon, especially the sigmoid flexure, and 
is without demonstrable cause, a fact proven by the clinical 
and pathological findings in almost every case. 

Classification. — Hirschsprung has suggested in one of 
his later papers the division of the cases into two groups: 
I. Those occurring in infancy (true megacolon). II. Those 
occurring in adult life (psendomegacolon). 



452 DISEASES OF ANUS, RECTUM, AND SIGMOID 

Marfan and Neter are very insistent upon an anatomic 
basis for the disease, namely, congenital elongation associated 
with loop formation in the colon. While this is not true in 
every case, as I point out later, still it is not out of place to 
call attention here to the fact that the large intestine, more 
perhaps than any other portion of the digestive tract, is liable 
to be the seat of malformations (Duval). The colon as a 
whole has a morphogenesis hardly completed, and the various 
changes in form, length, and position noted from time to time 
are probably but variations in the progressive evolution toward 
a final arrangement. 

The frequent anomalies are, in all probability, but rever- 
sion types. All the segments of the colon may be involved, 
but most often it concerns only that segment whose evolution 
is still unfinished, e.g., the sigmoid flexure. 

Johannessen has pointed out that the position of the sig- 
moid flexure is very changeable, and does not depend upon its 
mesentery alone, but also varies with the quantity and con- 
sistency of its contents. It is easy to see how these anatomic 
variations might materially influence the accumulation of 
faeces in the colon. 

Etiology. — It must be admitted at the outset that little is 
known as to the true cause of this affliction; indeed, it is a 
question whether a single cause could give rise to the various 
manifestations that have been noted by different observers as 
occurring in the course of the disease. The fact that so many 
theories as to its etiology have been advanced is the best evi- 
dence as to the uncertainty of our knowledge of the subject. 
It is highly probable that more than one etiological factor is 
concerned in its production, as no single cause that has been 
thus far discovered will satisfactorily explain every case. 
There have been suggested from time to time in the literature 
a number of different hypotheses in the endeavor to explain 
the causation of the affection. 

" Many writers have looked upon it as congenital, as it 
frequently occurs in childhood. Among them is Hirschsprung 



DILATATION OF THE COLON 453 

himself. Others, among them Fenwick and Treves, believe 
that the dilatation of the colon is first the result of mechanical 
obstruction, due either to a volvulus or a congenital stricture, 
or to a spastic contraction. They believe that when the dila- 
tation has passed a certain point it may continue, or possibly 
increase, even though a mechanical obstruction be removed. 
Other writers have explained megacolon as the result of dila- 
tation due to colitis and fermentation of the intestinal con- 
tents; still others have attributed it to the development of 
valves and kinks; while Ibrahim asserts that an undue length 
of the sigmoid is a sufficient cause for megacolon. Fig. 150 




-■-.;' 



\ 



Fig. 150. — Megacolon or Hirschsprung's disease. (Petrivalsky, Progressive Medicine.) 

(Progressive Medicine, Vol. XI, No. 2, June 1, 1909) gives 
a good idea of the appearance of the patient before operation. 
" In my own case the picture presented by the disease cor- 
responded in every respect to, and suggested very strongly, 
that presented by a lymphangiectasis as it is seen in other parts 
of the body, i.e., macroglossia, macrocheilia, etc. Here the 
most striking feature, next to the immense size of the colon, 
was the thickness of the mesocolon, which was composed 
chiefly of enlarged lymph glands and enormously dilated 
lymph and blood-vessels. The dilatation of the lymphatic and 
vascular systems in the mesocolon corresponded exactly with 
the dilated segment of the bowel. The whole appearance of 
the dilated and hypertrophied bowel suggested hypernutrition, 



454 DISEASES OF ANUS, RECTUM, AND SIGMOID 

a species of giantism, as it were, due to the increased amount 
of blood and lymph supplied to the affected portion. A section 
of the mesocolon together with one of the enlarged lymph 
glands removed at the time of the first operation showed noth- 
ing but a marked hyperplasia. That this hypothesis could 
explain all the cases seems very improbable, but that it may 
be the cause of a considerable number, however, seems equally 
probable since in a large proportion of the reported cases 
where the condition of the mesocolon is stated this same thick- 
ening and hypertrophy of the lymphatic and vascular ele- 
ments has been observed. 

" The clinical picture of the disease is usually a pronounced 
one. The cardinal symptoms are, obstinate constipation and 
an enlarged abdomen in a patient in fairly good health. The 
disease, as a rule, manifests itself very early in life; frequently 
the first passage of meconium being delayed several days. 
The constipation thus early begun may continue throughout 
life. In other cases the constipation may be noticed only after 
a few weeks, months, or even years. Under these circum- 
stances, a movement of the bowels is always brought about 
with difficulty and rarely without the aid of enemata or cathar- 
tics, except during the periods of diarrhoea, which will be 
referred to later. This extreme difficulty in producing an 
evacuation is one of the characteristics of the disease. Enor- 
mous quantities and great varieties of cathartics, together with 
frequent large enemata, have been used with little or no effect. 
Unusual postures, assumed by the patient during the act of 
defecation or passing of gas, are reported by a number of 
authors, such as leaning over the back of a chair, standing on 
the head, knee-chest position, etc. 

" The distention of the abdomen may be observed at birth, 
soon after, or at a later period, and is due to distention of the 
dilated portion of the colon with gas and faeces. The dimen- 
sions of the dilated abdomen are, at times, enormous ; the 
circumference may be greater than the height of the patient. 
On inspection, one is struck at once by the disparity between 



DILATATION OF THE COLON 4,55 

the size of the abdomen and the rest of the body, which is 
emaciated. The appearance of the abdomen is rather barrel- 
shaped. The greatest circumference lies usually somewhat 
above the umbilicus, the distance between the umbilicus and 
ensiform cartilage and the umbilicus and symphysis being 
very much increased over the normal. 

" Just as abnormal as the dilatation of the abdomen is the 
length of time during which, in many patients, there is no 
stool. Frequently one gets a history of the patient going a 
week without a movement, periods of five weeks (Johannes- 
sen), six weeks (Roth), nine weeks (Rolleston and Hay- 
ward), and three months (Gay) have been noted. After 
shorter or longer periods constipation frequently alternates 
with diarrhoea, which usually relieves somewhat the abdominal 
distention, but this relief is only temporary, the abdomen never 
entirely regaining its normal dimensions. 

" The face presents a rather dull, apathetic appearance. 
The skin is rather dry, harsh and leathery, except over the dis- 
tended abdomen, where it may be tense or shiny. The com- 
plexion is frequently sallow or pasty. The veins over the 
abdomen appear distended and prominent. The abdominal 
walls are thinned and through them vigorous peristaltic waves, 
or coils of distended intestine, may often be observed. A 
diastasis of the recti muscles may occasionally be present. 
One of the most striking features is the change that takes 
place in the costal angle and plane of the chest wall. The 
former is rendered very wide and obtuse ; the latter, instead of 
its normal approximately vertical position, as a result of the 
continuous pushing up of the diaphragm by the distended 
intestine becomes at times almost horizontal. 

" The abdominal distention may or may not be uniform. 
In some cases the distended intestinal coils can be seen or felt 
more prominently upon one side than upon the other, more 
especially on the left side. This was pronounced in my own 
case. On palpation, one may at times feel masses of hard 
fecal matter filling the distended bowel. At other times the 



456 DISEASES OF ANUS, RECTUM, AND SIGMOID 

abdomen is everywhere soft and is as a rule singularly free 
from tenderness. During the active peristalsis, the enlarged 
and distended loops of sigmoid can frequently be grasped in 
the fingers. On percussion the abdomen may be everywhere 
tympanitic, owing to the great accumulation of gases in the 
intestine. The area of liver dulness is much reduced and its 
lower border elevated considerably above the normal. At 
other times, dull areas may be elicited corresponding to the 
fecal impaction. Movable dulness has never been observed. 
Audible borborygmi have frequently been reported, sometimes 
so loud as to be heard in an adjoining room. 

" The fecal discharges from the intestine are perhaps char- 
acteristic. Sometimes they are very dry and inspissated, at 
other times putty-like in consistency and of rather character- 
istic yellowish, brownish or greenish color, and having a pecu- 
liarly offensive odor. At other times the discharges, both 
solid and gaseous, have been noted as odorless. Vomiting is 
not a constant symptom and when it occurs it takes place late 
in the course of the disease, and is usually referable to some 
intercurrent complication. Pain is also not a marked nor 
constant symptom, being more pronounced when diarrhoea is 
present, or during active peristalsis. 

"CEdema of the lower extremities and scrotum has been 
observed in a number of cases. 

" On rectal examination, the sphincter is usually normal, 
although Fenwick and others have described a spasm which 
they believe to be of etiological importance. The majority of 
observers, however, have failed to note anything suggesting 
this condition. The rectum itself is usually found to be empty 
and relatively normal, though a ballooning of its walls has 
been noted and this in a considerable percentage of cases. 
Of some significance this, for it indicates an obstruction 
farther up. Anal fissures are rarely present and a rectal tube 
can usually be passed unobstructed for a considerable distance, 
frequently evacuating large quantities of gas or liquid faeces. 



DILATATION OF THE COLON 457 

" Marked disturbances have been observed from time to 
time in the other structures of the body. The lungs will be 
found encroached upon by the changed position of the liver 
and the upward pressure of the diaphragm. The lower lobes 
of the lungs may be more or less atelectatic. Breathing will 
be largely costal. Dyspnoea, which may not be noticed at the 
beginning, may later become pronounced, interfering very 
seriously with the comfort and perhaps the life of the patient. 
Bronchitis or bronchopneumonia are not infrequently observed 
in the course of the disease, due, in all probability, to dis- 
turbed conditions in the chest, possibly to metastasis from the 
intestinal obstruction. The heart's action may also become 
very much interfered with, producing a weak and irregular 
pulse, dyspnoea, etc. The kidney function appears to be 
seldom disturbed, which seems surprising, seeing the increased 
intra-abdominal pressure, and the weight of the mass of con- 
tained faeces. Gee reports a case of double hydronephrosis 
associated with this condition, and Fenwick one of compres- 
sion of both ureters with grave hematuria. Roth has observed 
in two cases a peculiar deformity of the bladder, consisting of 
a cone-shaped dilatation extending to the umbilicus. Germer 
and others have also noticed this and it was present in one 
of the Johns Hopkins Hospital list. Great increase in the 
amount of indican is not unusual; albumin and casts are not 
usually found. 

" Eleven cases were recorded in the Johns Hopkins Hos- 
pital up to January I, 1908, nine males and two females, seven 
whites and four blacks, their ages ranging from seven months 
to fifty-five years. 

" As special aids to diagnosis in doubtful cases, enemata of 
bismuth and oil given in the knee-chest position, and an X-ray 
subsequently taken in the abdominal position, will give a 
fairly characteristic shadow. If the bismuth does not show in 
the descending or transverse colon, the distended loop must 
be the sigmoid. Diaphanoscopy may also at times be of 



458 DISEASES OF ANUS, RECTUM, AND SIGMOID 

service. Remember, in differentiating between tubercular 
peritonitis and this disease, that ascites has never been observed 
in connection with Hirschsprung's disease. 

" In advanced cases there may be necrosis or perforation, 
with resulting peritonitis. Sometimes the mesocolon is greatly 
thickened. On microscopic examination the changes of 
chronic inflammation are especially marked in the mucosa, 
while the hypertrophy of the muscular coats is extreme. In 
other cases there has been noted a great thickening of the sub- 
mucosa. While it is established beyond question that in many 
cases of megacolon no obstruction exists at the time of obser- 
vation, different writers are coming more and more to the 
view that obstruction at some former date was the starting 
point of the hypertrophy and over-development, even in the 
so-called congenital cases." {Progressive Medicine, June i, 
1909.) 

Prognosis. — The prognosis in Hirschsprung's Disease is 
always uncertain. While the disease itself is rarely 'rapidly 
fatal, still the patient always leads a precarious existence, 
owing to malnutrition and digestive disturbances incident to 
the trouble. Intercurrent affections are very commonly 
observed, and not infrequently the cause of death is due to 
one of these. Peritonitis, the result of perforation, heart 
failure, and disease of the respiratory organs, particularly 
bronchitis and bronchopneumonia, are the most common of 
the intercurrent affections. 

The prognosis is influenced by the age of the patient, and 
the younger the individual, the more unfavorable it must be. 

Treatment. — After rectal irrigations and cathartics have 
failed to afford relief, do a laparotomy at once, before the 
patient has become too emaciated by the prolonged absorption 
of toxic material. 

After varied experiences with colostomy, colopexy, entero- 
anastomosis. and resection of the affected portion of the bowel, 
with end-to-end or lateral anastomosis, the consensus of 
opinion at present is in favor of doing a primary anastomosis 



DILATATION OF THE COLON 



459 



between the ileum and the lower portion of the sigmoid or 
rectum (Fig. 151, Bloodgood) to relieve immediate symp- 
toms and to enable the patient to be better prepared for sub- 
sequent resection of the hypertrophied and dilated colon. 




Fig. 151. — Lateral anastomosis between the ileum and sigmoid. (Bloodgood.) 

Pathology. — The principal seat of the pathological 
process is in the large intestine, and in more than one third 
of all the cases the sigmoid flexure is alone involved (Fig. 



460 DISEASES OF ANUS, RECTUM, AND SIGMOID 

152). In practically all cases it was included in the affected 
portion : the whole of the large intestine was found involved 
in about 15 per cent., but the rectum and small intestine are 
rarely affected. In addition to the small intestine, the stomach 
(Gourevitch), the appendix (Muhlberger and Tschernow), 
and the oesophagus (Bergman), have been reported as taking 
part in the dilatation. The transition from the normal to the 
dilated portion is usually gradual, but may be abrupt, whereas 
the transition from the dilated portion to the normal is usually 




FlG. 152. — Case of redundant sigmoid in a four-year-old boy. This was evidently 
the initial stage of Hirschsprung's disease. The child suffered daily with intense colic, and 
with rarer attacks of almost complete intestinal obstruction. Fourteen inches of the 
sigmoid flexure were resected, followed by an end-to-end anastomosis. Recovery of child 
with complete disappearance of symptoms. (J. G. Clark.) 

the reverse. There may or may not be evidence of mechanical 
obstruction of one form or another. These demonstrable 
forms of mechanical obstruction are more frequently met 
with in the adult than in the child, and may give rise to symp- 
toms erroneously classified as Hirschsprung's Disease. A 
pathological study of many of so-called cases would undoubt- 
edly show them to be of a pseudomegacolic nature. As 
pointed out by Perthes, the characteristic of congenital idio- 



DILATATION OF THE COLON 461 

pathic dilatation of the colon (true megacolon) is the inability 
to demonstrate a definite mechanical obstruction at an opera- 
tion, or autopsy. Upon opening the abdomen of a patient, 
the subject of this disease, one is at once struck by the enor- 
mous dilatation of the colon in whole or in part. The dimen- 
sions of the dilated portion are at times prodigious, reaching 
the diameter of six to eight inches (Treves, Hawkins, Formad, 
etc.). Its capacity is at times even more striking. Peacock's 
case contained sixteen litres, Formad's cases forty pounds, etc. 
The dilated portion occupies a prominent position in the abdo- 
men, filling almost the entire cavity, pushing aside and com- 
pressing the small intestine and the remaining organs, fre- 
quently obscuring them entirely from view. The large intes- 
tine instead of following its usual arrangement disposes itself 
in two parallel limbs, running more or less perpendicularly. 

The walls of the intestine show marked changes as the 
result of dilatation and hypertrophy : the serous coat is usually 
roughened, the ruga less pronounced, or obliterated. The 
whole colon may at times appear elongated, with increased 
loop formation as described by Marfan and Neter. 

In advanced cases peritonitis may be present, due to necro- 
sis of the intestinal wall and resulting perforation. External 
evidences of this necrosis may be found in the bowel wall, 
which is palpably thickened in most cases. The mesocolon is 
the seat of well-marked changes, consisting in variations in 
length, sometimes longer and sometimes shorter. At times 
it is of great thickness, due to the immense increase in the 
lymphatic and vascular elements, as manifested in the enor- 
mous dilatation of the lymph and blood-vessels and the in- 
creased size of the lymph glands, a condition resembling very 
closely lymphangiectasis. Upon opening the intestine, faeces 
in large quantities may be evacuated. As already pointed out, 
the intestinal contents are rather characteristic in color, con- 
sistency, and odor. The mucosa is frequently markedly pig*- 
mented, sharing to a certain extent in the hypertrophy of the 
rest of the intestinal wall. Patches of ulceration can fre- 



462 DISEASES OF ANUS, RECTUM, AND SIGMOID 

quently be seen occupying larger or smaller areas and varying 
in depth from slight erosions to complete perforations. 

Microscopic examination of the wall of the tremendous 
colon of Hirschsprung's Disease shows an interesting picture. 
In general we have to deal with a quite uniform hypertrophy 
of all the intestinal tunics, especially marked, however, in the 
muscularis, and grafted as it were on this hypertrophy are 
many degenerative changes. 

" The greatest interest in the pathological anatomy lies in 
what suggestions it might give as to the causative factors 
involved. I own frankly that here, as often elsewhere, no 
real light has been shed on the question of pathogenesis, and 
this is certainly true in spite of the various interpretations of 
the histological picture made from time to time. 

" Such a picture may be considered now as relatively con- 
stant, for on it all careful reports agree and it will support 
most of the various theories which have been advanced to 
explain Hirschsprung's Disease. It will prove none of them." 



AUTHORITIES CONSULTED 



Abbott, Amos, W., 37 

Adami, 352, 360, 362, 365, 367, 

3 8 9, 397 
Adler, Lewis H., Jr., ^33, 360 . 
iEgineta, Paulus, 174 
Allingham, 111, 259, 281, 290, 347, 

440 
Amussat, 176, 177, 401 
Arlving, 25 
Arthur, 401 

Babcock, W. W., 54 

Ball, Sir Charles, 145, 147, 165, 

3 IO > 333, 335. 336, 369 
Banks, 451 
Bartholin, 234 
Beach, William, 330 
Bell, Benjamin, 174 
Bellela, 369 
Bennett, 203 
Berard, 175 
Bergman, 460 
Bier, 54 
Billard, 450 
Billroth, 401 
Birch, 65 
Blake, 139 

Bloodgood, 403, 421, 459 
Bmmer, George, 385 
Bouchard, 68 
Boyer, 169 
Braune, 55, 372, 443 
Breschat, 175 

Brewer, George Emerson, 102, 104 
Brewster, Roger B., 50 
Brown, E. J., 50 
Bruning, 54 

Buckler, Warren H., 55 
Bunfer, 451 
Burnam, Curtis F., 82 



Campbell, John P., 175 

Cannon, 21 

Chautre, 25 

Chetwood, 94, 220 

Clark, J. G., 82 

Clegg, 125, 126, 128 

Cohnheim, 353 

Combs, G. W., 436 

Cooke, A. Bennett, 81, 107, 109 

Councilman, W. T., 122, 354 

Cowper, 225 

Cripps, 310, 381 

Cullen, Thomas S., 102, 233, 330 

Cunningham, John H., Jr., 298, 299, 

300 
Cusack, 261 

Danzel, 373 
Davidson, 44 
Davis, S. Griffith, 55 
Desguins, 401, 415 
Dieffenbach, 175, 296, 404 
Douglas, 13, 19 
Durham, 320 
Duval, 452 

Earle, 49, 166, 167, 269, 275, 290 

Eldridge. 125 

Emmet, 237 

Esmarch, 48 

Evans, George B., 369 

Ewald, 74, in 

Favalli, 451 

Fenwick, 453, 456, 457 

Finet, 396 

Finney, J. M. T., 108, 450, 451 

Fisher, W. A., 451 

Formad, 451, 461 

Fournier, 144, 313 

463 



AUTHORITIES CONSULTED 



Fowler, George R., 291, 294 
Frankl-Hochwart, 25 
Frohlich, 25 
Futcher, 451 

Gallant, 268 

Galloway, 451 

Gant, Samuel G., 47, 131, 132, 134, 

135, J3 6 , 2 97, 347, 447 
Gay, 451, 455 
Gee, 457 
Germer, 457 
Gerrish, 6 

Gibson, 129, 130, 132 
Giordano, 402 
Glisson, 14 
Goltz, 24, 25 
Goodell, William, 438 
Goodsall, 203, 213, 215 
Gould, 338, 362 
Gourevitch, 460 
Graham, Alois B., 188 
Guibe, 150 
Guillon, 175 
Gwathney, 55 

Hahn, Henry J., 324 

Hamman, Louis, 224 

Hamonic, 99, 144 

Hanes, 29, 250 

Hardouin, 191 

Hartmann, 163, 312, 389 

Hawkins, 461 

Hayward, 455 

Hazzard, Thomas L., 71 

Hebb, Arthur, 201, 270, 271 

Heister, Laurence, 174 

Henock, 451 

Hensing, 20 

Hertzler, Arthur E., 50, 51, 52 

Hill, T. C, 330 

Hilton, 249, 275 

Hirschman, Louis J., 188, 309 

Hirschsprung, 450, 451, 452, 460, 

462 
Hirsh, Jose L., 326 
Holmes, 443 



Holtman, 371 

Houston, 5, 13, 14, 15, 67, 77, 308 
Howell, W. H., 21, 22, 24 
Hutchinson, Copeland, 175 

Ibrahim, 453 

Illoway, H., 57, 65, 66, 67, 68 

Jelks, J. J., 128 
Johannessen, 452, 455 
Jonnesco, 18 
Jordan, Furneaux, 161 
Junker, 55 

Kaabak, 107 

Kelly, Howard A., 39, 108, 320, 419, 

420, 427 
Kelsey, 144, 168, 306 
Kemp, 94 
Klose, 50 
Koch, 324 
Kohlrausch, 6 
Kraske, 236, 323, 401, 409, 417, 424, 

425 
Kreuse, 128 
Kronig-Wertheim, 423 
Krouse, Louis J., 335 

Lange, 291 

Langley, 7 

Lapeyre, 108 

Lauenstein, 236 

Laws, 36 

Lee, Henry, 261 

Legueu, F., 54, 227 

Lembert, 96, 420 

Levy, 401 

Lewis, Bransford, 43 

Lewitt, 451 

Lieberkuhn, 12, 26, 92, 99, 122, 

35 6 , 380, 381 
Lieserink. 178 
Lilienthal, 371 
Linthicum, G. Milton, 263 
Little, 451 
Littre, 191 
Lockyer, 138 



AUTHORITIES CONSULTED 



465 



Loffler, 145 

Lowenstein, 450 

Luschka. 2, 19, 443 

Lynch, Jerome M., 49, 80, 169, 303, 

Lyon, Irving Phillips, 82 

McBurney, 134 

McElfresh, C. W., 195, 242 

Malgaigne, 175 

Mallory, 51 

Marfan, 452, 461 

Marshall, H. T., 126 

Martin, Collier F., 53, 252, 254, 257 

Martin, Robert W., 252 

Martin, T. C, 15, 16, 77, 78, 79, 

320, 335 
Mastin, W. M., 173 
Matthews, J. M., 29, 75, 98, 250, 

259, 320, 439 
Maunsell, 402 
Mayo, 102 
Meirowsky, 397 
Middeldorpf, 372 
Mikulicz, 303 
Miles, 203, 215, 422, 423 
Milton, Frank, 145, 149 
Mitchell, 312 

Morgagni, 10, 12, 14, 249, 280, 329 
Muhlberger, 460 
Murphy, 415, 417 
Murray, Dwight H., 35, 43, 74, 93, 

263 
Musgrave, 125, 126, 128 
Mya, 451 

Neter, 452, 461 
Norton, 415 
Nothnagel, in 
Nott, J. C, 445 

O'Beirne, 13, 15, 26, 62 
O' Donovan, 123 
Ombredanne, 18 
Ord, 373 
Osier, 451 



Oulmont, 451 
Outerbridge, 268 



ge, 3 73 
Parkhill, 269 
Parry, 450 
Pasquale, 128 
Peacock, 461 
Pennington, J. Rawson, 15, 16, 38, 

79, 103, 264 
Perthes, 460 
Piatt, 294 
Poupart, 20, 342 
Price, 401 

Quenu, 8, 17, 99, 389, 402, 404, 430 

Rehn, 409 

Reynolds, Charles B., 54 

Richet, 158, 227 

Rizzoli, 190 

Roberts, 296 

Roberts, Dudley, 39 

Robinson, Byron, 102, 103 

Rogers, 129 

Rogers, Ford B., 30, 51 

Rolleston, 255 

Rontgen, 21 

Rosenheim, 66 

Rosenschein, 107 

Roser, 20 

Rossle, 397 

Roth, 455, 457 

Rotter, 371 

Roux de Brignolles, 175 

Rydgier, 323, 409 

Schaeffer, 15 

Schmey, 288 

Schnitzler, 385 

Shaffer, 1 

Shiga, 124, 125 

Shuldham, 139 

Simon, 33 

Simpson, J. Y., 447 

Sims, 27, 31, 35, 37, 74, 166, 320 

Skutsch, 373 



466 



AUTHORITIES CONSULTED 



Smith, Henry, 261 
Smith, Nathan R., 281 
Staff el, 397 
Stromeyer, 178 
Stroud, 2 

Sutton, J. Bland-, 351, 366, 373,381, 
398 

Telling, 95, 102, 104 

Testut, 17 

Thibault, Henry, 50, 51 

Thiersch, 353 

Toupet, 312 

Treitz, 6 

Trendelenburg, 228, 341, 424 

Treves, 453, 461 

Tschernow, 460 

Tuttle, James P., 7, 36, 37, 38, 99, 
108, 134, 144, 169, 201, 209, 230, 
233, 2 37, 261, 368, 370, 377, 378, 
382, 389, 395, 396, 404, 408, 409, 
4i5» 4i6, 417, 427 

Urban, 54 

Van Buren, 290 
Velpeau, 175, 404 



Verneuil, 291, 401, 404 
Vidal de Cassis, 175 
Vincent, 182, 184 
Vogt, 54 
Von Ammon, 450 

Wales, 44, 319 

Wallis, F. C, 114, 330 

Watson, 428 

Weigert, 51 

Weir, R. F., 129, 134 

Welch, William H., 240 

Wertheim, 423 

White, W. Hale, 109, no 

Whitehead, Walter, 266, 267, 268, 

270, 273, 274, 275, 290 
Williams, W. Roger, 350, 352, 364 
Witzenhauser, I., 52 
Wolbarst, A. L., 94 
Wolman, Samuel, 224 

X-ray, 120 

Young, Hugh H., 228 

Ziegler, 355, 363, 377, 379, 381, 398 
Zobel, A. J., 138, 204 



INDEX 



Abscess, deep, 158 

idiopathic gangrenous peri- 
proctitis, 161 
etiology, 162 
symptoms, 162 
treatment, 162 
interstitial, 162 
retrorectal, 158 
symptoms, 158 
treatment, 159 
superior pelvirectal, 159 
diagnosis, 160 
symptoms, 159 
treatment, 160 
perianal and perirectal, 151 
superficial, classification, 152 
follicular, 152 

treatment, 153 
ischiorectal, 155 
symptoms, 156 
treatment, 157 
subtegumentary, 153 
symptoms, 153 
treatment, 155 
Adenocarcinoma (see Carcinoma) 
Anatomy, anal canal, 9 
development, 1 
fasciae, 3 
fossae, 3 

Luschka, gland of, 2 
lymphatics, anus, rectum, 8 

inferior hemorrhoidal plex- 
us, 8 
middle hemorrhiodal plex- 
us, 8 
superior hemorrhoidal plex- 
us, 8 
anorectal, 4 
coccygeus, 6 
corrugator cutis ani, 4 



Anatomy, lymphatics, external 
sphincter, 4 
internal sphincter, 5 
levator ani, 5 
perineal, 4 
rectococcygeus, 6 
third sphincter, 5 
nerve supply, anus and rectum, 7 
cerebrospinal, 7 
pudic nerve, 8 
sympathetic, 7 
"pecten," 2 
pelvic triangles, 2 
rectum, 10 
ampulla, 11 
arteries, 16 

inferior hemorrhoidal, 16 
middle hemorrhoidal, 16 
middle sacral, 17 
superior hemorrhoidal, 16 
cellular spaces, 17 
Glisson's pillars, 14 
goblet-cells, 12 
Houston's valves, 14 
Lieberkuhn glands, 12 
longitudinal musuclar layer, 13 
Morgagni, columns of, 14 

crypts of, 14 
mucous membrane, 12 
epithelial layer, 12 
structure, 12 
muscularis mucosa, 12 
muscular wall, 12 

circular layer, 13 
O'Beirne, valve of, 15 
prostatovesical cul-de-sac, 19 
serous coat, 13 

Douglas's cul-de-sac, 13 
submucous layer, 12 
veins, 17 

467 



468 



INDEX 



Anatomy, sigmoid flexure, 19 
blood supply, 21 
nerve supply, 2 1 
serous layer, 20 
ligament, Poupart's, 20 
muscular layer, 20 
submucous layers, 20 

Carcinoma, adenocarcinoma, con- 
stitutional symptoms, 

. 387 
curette in, 393 

examination, 387 

hemorrhages, 386 

secondary, 386 
adenoid, 374 
attachments, 388 
colostomy as palliative, 393 
diagnosis, 389 
entero-anastomosis in, 394 
epitheliomatous, 374 
excision, resection, 395 
inoperable, 392 
intestinal, 375 
irrigations, 392 
medullary, 374 

curette in, 393 

involvement of other organs, 

387 
symptoms, 387 
mortality, 396 
neoplasms, 378 
operable, 395 

perirectal abscesses in, 388 , 
rupture of bowel, 388 
scirrhous, 374 
sigmoidal, 390 
treatment, 390 
curette, 393 
X-ray, 394 
Coccyx, pathological lesions, 442 
coccygodynia, Nott, 445 
diagnosis, 446 
etiology, pathology, 446 
symptoms, 446 
treatment, palliative, 446 
excision, total, Gant, 447 



Coccyx, fractures, dislocations, 442 
treatment, 443 
malformations, 442 
sacrococcygeal tumors and 
cysts, 443 
abscesses, 444 
classification, Holmes, 

443 
congenital, 444 
constipation, 444 
digital examination, 444 
extirpation, 445 
resection, partial, 445 
tapping, 444 
tenotomy, Simpson, 447 
treatment, 444 
Colitis (see Membranous colitis) 
Colostomy, 338 

closure of temporary anus, 348 
compress and receiver combined, 

345 
left inguinal, 339 
localities, 339 
P viil's tube, 347 
temporary operation, 345 
Constipation, acute, absence of 
or defective bile, 58 
direct inhibition of peristaltic 

function, 58 
direct obstruction of lumen of 
intestine, 58 
atony of intestine, 62 
bad teeth, 65 
chronic, 59 

atony of intestinal muscle, 61 
bowel dislocation, 61 
chronic venous congestion, 60 
congenital malformation, 59 
foreign bodies, 59, 61 
functional impairment, 59, 61 
inhibition of peristalsis, 60 
malformations of intestines, 61 
morbid processes, 59 
mucous membrane, changes 

in, 60 
primary atrophy of large 
bowel, 61 



INDEX 



469 



Constipation, secretory impair- 
ment, 60 

voluntary abstention from 
stool, 60 
clysters and position, 73 
cold water in, 64 
combination of causes, 59 
consequences, 67 
diagnosis, 66 

enterospasm and atony, 62 
etiology, 57, 66 
exercise, 64 
food deficient in fats, 64 

deficient in residual matter, 63 
habitual purgation, 65 
Illoway's classification, 57 
impaction, hydrogen peroxide, 

Cooke, 81 
imperfect physiolog. function, 62 
irritable sphincter, 62 
mental work, 65 
mental worry, 65 
muscular aid, 58 
obesity, 65 
old age, 65 

pathological changes, 58 
perverted action, 62 
prognosis, 67 
psychotherapy, cure permanent, 

91 

habit, 83 

length of treatment, 90 

Lyon and Burnam, 82 

relapse, 91 

results, 90 

statistics, 90 
reading at stool, 63 
spasmodic stricture, 62 
spastic, 62 
symptoms, 65 

etiology, 66 

unusual, 65 
treatment, 69 

clysters, 72 

cold baths, 72 
compresses, 73 
moist friction, 73 



Constipation, diet, 69 
drink, 70 
electricity, 70, 74 
exercise, 70 
hydrotherapy, 70-72 
impaction, 80 

lateral anastomosis, Clark, 82 
massage, 70 
muscular tone, 69 
operative, 77 
psychotherapy, 82 
removal of cause, 69 
"A Rational," Murray, 74 
sigmoidopexy, 82 
therapeutic, 76 
valvotomy angiotribe, Lynch, 

80 
valvotomy clip, Pennington, 

79 
valvotomy, Martin, 77 
warm water injections, 65 
weakness of abdominal walls, 64 

Examination, alligator forceps, 
Bransford Lewis, 43 
anaesthesia in rectal diseases, 47 
anaesthesia, general, chloroform 
in, Esmarch, 56 
ether in, 55 

Junker, Braun, Gwathney, 

55 

ethyl chloride in, 55 

morphia, atropia and strych- 
nia preceding, 55 

nitrous oxide and oxygen, 
H. Warren Buckler on, 55 

nitrous oxide and oxygen, 
morphia preceding, 55 

nitrous oxide and oxygen, 
S. Griffith Davis on, 55 

nitrous oxide and oxygen 
preliminary to ether, 55 
anaesthesia, local, cocain or beta- 
eucain, 48 

cocain anaesthesia and hem- 
orrhage, 50 

objections to, 50 



470 



INDEX 



Examination, quinin and urea hy- 
drochloric!, 50 
quinin and urea hydrochlo- 

rid fibrinous exudate, 51 
quinin and urea hydrochlo- 

rid, skin union, 51 
quinin and urea hydrochlo- 
rid, delayed skin union in, 
52 
quinin and urea hydrochlo- 

rid, duration of, 52 
suitable cases, 49 
technic, Tuttle, 48 
anaesthesia, spinal, 53 
arrest of respiration, 54 
cerebral hemorrhage from, 

54 
pain in legs, 54 
paraplegia, pyelonephritis, 

54 
Reynolds, Chas. B., on, 54 
appliances, light, 33 
applicators, dressing forceps, 42 
bougies, 44 

old English, 44 
Wales, 44 
digital, 32 

dilators: dilatable rubber bags, 
Dudley Roberts, 39 
advantages of, in stric- 
tures, 42 
dilators, Kelly, 39 
dressing forceps, 42 
external, 31 
fasces, 45 

enteroliths, 46 

mucus, blood, and pus, 46-47 
history, 27 
position, 27 

probes, grooved directors, 43 
proctoscope and sigmoidoscope, 
Laws, 36 
Tuttle, 36 
description, 38 
scrotal holder, shield, Murray, 43 
specula, 35 
Earle, 35 



Examination, specula, Murray, 35 

Pennington, 38 

Sims's vaginal, 35 
Extirpation, abdominal, 418 
colorectostomy, Kelly, 419 
colostomy, Bloodgood, 403 
combined, 420 

Bloodgood on, 421 

Miles on, 422 
curetting, 404 
diet, 402 
history, 401 
irrigation, 403 
perineal, 404 
Quenu on, 404 
rectum, 401 
sacral, Kraske's operation, 409 

objections to, 415 

Tuttle's modification, 409 
Tuttle on, 404 
vaginal, 415 

review of, 415 

technic, Murphy, Tuttle, 417 

Fissure, complications, 170 
diagnosis, 166 
etiology, 164 
excision, 170 
in ano, pathology, 163 
incision in, 169 
symptoms, 165 

reflex, 166 
treatment, 167 

operative, 167 
Fissure in ano, or painful ulcer, 163 
Fistula, anorectal, 192 

"barriers set by nature," 199 

blind external, 195 

blind internal, hawk-bill knife, 

Earle, 206 
classification, 193 
complete, 196 
complex, 213 
complicated, 223 
excision, 208 

Tuttle, 209 

with immediate suture, 208 



INDEX 



471 



Fistula, incontinence, Chetwood 

treatment, 220 
injections, medicated, 203 
multiple internal opening, 215 
origin, 197 
pathology of, 197 
perineal, 225 

treatment, 226 
rectogenital, 233 
recto-ureteral, 233 
recto-urethral, 226 

diagnosis, 226 

etiology, 226 

treatment, 227 

Young's operation, 228 
recto-uterine, 233 
rectovaginal, 235 

Lauenstein operation, 236 

symptoms, 235 

treatment, 235 
rectovesical and enterovesical, 
230 
diagnosis, 231 
prognosis, 231 
symptoms, 231 
treatment, 232 
rectovulvar, 234 
sex, 194 

spontaneous healing of, 198 
submuscular or subaponeurotic, 

197 
symptoms, 195 
syphilis, 194 
treatment, 202 

non-operative, 202 

operative, 203, 217 
tubercular, prognosis in, 199 

test for diagnosis, 224 
tuberculosis, 194 
urinary, 225 
Foreign bodies, etc., antiseptics 
following removal of, 435 

causes, predisposing, 452 

cceliotomy, 436 

complications, 434 

diagnosis, 434 

enteroliths, 432 



Foreign bodies, prognosis, 434 
rectum, sigmoid, 432 
symptoms, 433 

genito-urinary, 433 
treatment, 434 

anaesthesia in, 435 

Hemorrhoids, 240 

capillary, symptoms, 248 

treatment, 257 
cathartics, 244 
causes other than pathological, 

244 
complications, 241 
connective-tissue, 247, 248 
constipation, 243 
etiology, 241 
external, 244 
internal, 244 
capillary, 248 

clamp and cautery in, 261, 262 
divulsion of sphincter, 256 
electrolysis, 257 
excision, complications, 273 
Earle method, 269 

modification of, 275 
Earle 's clamp, 269 
Hebb's clamp, 270 
Hebb's scissors, 271 
immediate suture, 266 
Parkhill method, 269 
Whitehead method, 266 
injection, 253 

divulsion of sphincter under 
nitrous oxid, 256 
ligature operation, 259 
Martin's injection method, 252 
operation, 252 

Pennington, 264 
thrombotic, 249 
treatment, palliative, 251 
varicose, 248 

after-treatment, 260 
anaesthesia in, 259 
dressings, 260 
varicose and thrombotic, 25S 
mixed, 249 



472 



INDEX 



Hemorrhoids, operation, erysipelas 
following, 278 
fissure following, 278 
infection following, 278 
secondary hemorrhage, 276 
tetanus following, 278 
ulceration following, 278 
pathology, 240 
post - operative complications, 

276 
predisposing causes, 242 
strain, 244 
thrombotic, 244 
treatment, 245 
varicose external, 246, 247 
operation, 247 
Hirschsprung's disease, classifica- 
tion, 451 
dilatation of colon, enormous, 

461 
etiology, 452 
hydronephrosis, 457 
mechanical obstruction, 460 
microscopic examination, 462 
mucosa pigmentation, 461 
pathology, 459 
peritonitis, 461 
prognosis, 458 
review of, Finney, 450 
symptoms, cardinal, 454 
treatment, 458 
versus tubercular peritonitis, 

458 
X-ray, 457 
Hysterical or irritable rectum, 438 
and anal fissure, 438 
and diseased ovaries or 

uterus, 438 
effect of excitement on, 439 
exhaustion following defe- 
cation, 438 
foreign bodies in crypts, 439 
gout and rheumatism, 440 
irritations, reflex, 439 
pathological cause, absence 

of, 439 
pressure of fecal mass, 439 



Hysterical rectum, sensibility, nor- 
mal, loss of, 440 
treatment, 440 
anaemia, 441 
autotoxaemia, 441 
enlarged prostate, 441 
nervous exhaustion, 441 
prolapsed ovary, 441 
retroverted or prolapsed 

uterus, 441 
stricture, 441 

Malformations, anus, 172 

anus and rectum, treatment, 172 
colostomy, 186 
locating rectum, 179 
measurements, infantile pelvis, 

183 
rectum, 172 

treatment, abnormal narrowing, 
186 
abnormal outlet, 186 
anal cul-de-sac, 185 
membranous diaphragm, 186 
operation, 180 

partial occlusion by band, 186 
rectum communicating with 

uterus, 190 
rectum opening into vagina, 

188 
surgical, resume, Mastin, 173 
ureters, uterus, or vagina open- 
ing into rectum, 190 
Malignant growths, adenocarci- 
noma, 380 
metastasis, 381 
cancer, scirrhous, 382 
carcinoma, medullary, 381 
colloid degeneration, 383 
epithelioma, 379 
rectal shelf, Blumer, 385 

due to metastasis, 385 
' ' Signet-ring stricture , ' ' 
Schnitzler, 385 
scirrhous carcinoma, consti- 
pation, 386 
symptoms, 383 



INDEX 



473 



Membranous colitis, adhesions, 107 

colon, fixation of, 107 

constipation, no 

enteroptosis due to, 109 

etiology, 106 

female generative organs, dis- 
placements of, no 

kidney, floating, 109 

lesions in mucosa, Cooke, 107 

malignant disease with, 109 

mucous colitis and appendici- 
tis, Kelly, 108 

mucous discharge, no 

simple, specific, 106 

symptoms, no 

treatment, in 

Pathological growths, adenoma, 
354, 366 
causes, 368 
adenomatosis, 367 
case of, Evans, 369 
colostomy and caecostomy, 

37i 
diagnosis, 369 
Lynch's electric angiotribe, 

37o 
malignant transformation, 

37o 

symptoms, 369 

treatment, 370 
angioma, 3 54, 3 59 

case of, Adler, 360 

derivation of, 360 
carcinoma, epithelial, 354 

glandular, 355 
condyloma acuminatum, 363 
definition, 350 
dermoids of rectum, 371 
enchondroma, 354, 359 
epithelial carcinoma, 354 
fibroma, 357 
lipoma, 354, 358 

treatment, 359 
lymphoma, 3 54, 3 59 
malignancy, Cohnheim the- 
ory, 3 53 



Pathological growths, malignant, 
two genera of, sarcoma, car- 
cinoma, 351 
myxoma, 354, 358 
papillas, hypertrophied anal, 

3 74 
papilloma, 354, 364 
etiology, 362 
hard, warts, 362 
inflammatory fibrous, 363 
polypus, 357 
adenoma, 356 
cystoma, 356 
diagnosis, 357 
fibroma, 356 
histological types, 356 
lipoma, 356 
postanal dimples, 373 

treatment, 374 
postrectal dermoids, 372 
rectal dermoids, 373 
treatment, 373 
with hair, 373 
sarcoma, 3 54 
alveolar, 354 
chloroma, 354 
melano, 354 
round-cell, 354 
spindle-cell, 354 
teratoma!, 355, 371 
treatment, 357 
tumors, benign, 355 
classification, 354 
innocent, 350 
malignant, 350 
villous," 365 
Physiology, anus, rectum, and sig- 
moid, 2 1 
defecation, 23 
nervi erigentes, 22 
O'Beirne theory, 26 
Proctitis, acute catarrhal, etiology, 
92 
catarrhal, atrophic, 98 
etiology, 99 
local applications, 100 
pathology, 98 



474 



INDEX 



Proctitis, catarrhal, atrophic, symp- 
toms, 99 
treatment, ioo 
chronic, 96 
diet, 97 

hypertrophic catarrh, 96 
medicinal treatment, 97 
pathological changes, 96 
symptoms, 96 
treatment, 97 
simple catarrhal, 92 

pigmentation of rectal mu- 
cous membrane, Murray, 93 
symptoms, 93 
treatment, 93 

rectal irrigator, Wolbarst, 93 
Prolapse, rectum, 279 

complete, cold applications, 
289 
complications, 303 

rupture of hernial sac, 306 
degrees of, 282 
divisions of, 279 
excision, 298 

Cunningham's method, 
298 
first degree, 282, 283 
operative treatment, 290 
Dieffenbach-Roberts, 296 
Lange, 291 

modification of, Verne- 
uil, 291 
Whitehead, 290 

Earle's modification, 290 
pathology, 287 
phosphorus in, 288 
polypi on, 284 
rectopexy, Tuttle, 291 
second degree, 283, 284 
sloughing, 289 
third degree, 283 
etiology, 286 
reduction, 288 
sigmoidopexy in, 296 

Gant, 297 
symptoms, 286 
treatment, 287, 296 



Prolapse, rectum, kangaroo tendon 
ligature, 294 
incomplete, 279 
etiology, 279 

excision with immediate su- 
ture, 282 
symptoms 280 
treatment, 281 
nitric acid, 281 
Pruritus ani, 328 

Ball's operation, 333 

modification of, Krouse, 

335 
modification of, Martin, 

335 
blind sinuses, 329 
catarrhal conditions, 330 
constitutional causation, 328 
dermatitis, 329 
direct causation, 32 8 
eczema, 329 
erythema, 329 
external causation, 329 
hemorrhoids, 330 
herpes, 329 
ointment, nitrate of mercury, 

Adler, ^33 
papillomas, hard, 337 
parasites, 329 
pediculi, 329 
reflex causation, 328 
symptoms, 330 
treatment, 331 
ulceration, anorectal, 330 
uterine fibroid, 330 
X-ray, high-frequency, 337 

Sarcoma, age, 399 
cachexia, 400 
chondrosarcoma, 398 
definition of, 396 
diagnosis, 400 
hemorrhage, 399 
lymphosarcoma, 398 
melanotic, 397 

metastasis along blood stream, 
397 



INDEX 



475 



Sarcoma, myosarcoma, 398 
primary or secondary, 399 
prognosis, 400 
rectal, 399 

sarcoma cells, capillaries, 396 
treatment, 400 
X-ray or radium, 400 
Sigmoiditis, 101 

diagnosis, differential, 104 
diverticulitis, 102 

acute, groups, Brewer, 104 
symptoms, 105 
treatment, operative, 105 
interstitial, 102 
perisigmoiditis, 102 
sigmoid overloaded, Pennington, 

103 
symptoms, 10 1 
treatment, 103 
Stricture, classification, annular, 

tubular, linear, 308 
colostomy, 322 
congenital, 309 

treatment, 309 
diagnosis, 316 
dilatation, gradual, 319 

rapid, 320 

rectal wall, 316 
electrolysis, 318 
excision, 322, 324 

perineal, 322 

sacral, 323 
fistula?, 314 

inflammatory, location, 310 
neoplastic, intramural, 309 
operative treatment, 320 
pathology, 313 
proctoplasty, 327 
proctotomy, partial, 320 

posterior, complete, 320 
rectal, 308 

simple inflammatory, 311 
spasmodic, 309, 310 
symptoms, 314 
syphilitic, 312 
traumatic, 311 
treatment, 317 



Stricture, tubercular, 312 

Tumors, malignant, 374 
carcinomas, 374 

four elementary types, 374 

Ulceration, actinomycosis, 149 
anal canal, 114 

chancroid, etiology, 139 
symptoms, 114 
treatment, 114 
anorectal syphiloma, Fournier, 

144 
appendicostomy, Gant's irriga- 
tor, 135 
Weir, 134 
Bilharzia and carcinoma, 149 

treatment, 149 
caecostomy and appendicostomy, 
closure of openings, 137 
valvular, 129 
Gant, 131 
Gibson, 130 
diphtheritic, 145 
dysenteric, 124 
etiology, 124 
dysentery, amoebic, 125 
diagnosis, 127 
location of ulcers, 127 
symptoms, 128 
treatment, 128 
bacillary, 124 
symptoms, 124 
treatment, 125 
eczematous, 114 
treatment, 114 
follicular, etiology, 117 
symptoms, 117 
treatment, 117 
gangrene, 150 
spontaneous, 150 
thrombotic, 150 
gonorrhceal proctitis, 138 
prognosis, 139 
symptoms, 138 
treatment, 139 
hemorrhoidal, 116 



476 



INDEX 



Ulceration, hemorrhoidal, treat- 
ment, 116 
herpetic, 114 

treatment, 1 14 
infections, mixed, 137 
pathology, 137 
treatment, 137 
irrigations, solutions, 137 
lupoid, 120 

malignant, perianal region, 120 
perianal, traumatic, 113 

treatment, 113 
proctitis, acute tubercular, 122 
rectum, chancroidal, treatment, 
140 
sigmoid and ,115 
follicular, 117 
simple, predisposing causes, 

115 
symptoms, 115 
treatment, 116 
rodent, 120 
simple perianal, 113 
specific, 113, 118 
stricture, symptoms, 118 
syphilitic, 141 
congenital, 144 

treatment, 145 
phagedenic, 141 
proliferating proctitis, 144 
secondary, 142 



Ulceration, hemorrhoidal, second- 
ary, treatment, 143 
spirochaeta pallida, 141 
tertiary, destructive, 144 
gummata, 143 
lesions, 143 
treatment, 144 
tubercular, 118 
diagnosis, 122 
miliary, 119 
symptoms, 122 
treatment, 122 

ulcerative type, treatment, 
119 
venereal, anus and rectum, 138 
verrucous, 120 
treatment, 120 

Wounds, etc., bladder involve- 
ment, 428 

gun-shot wounds, civil war, 428 
Franco-Prussian war, 428 

prognosis, 428 

rectum, rupture of, 427 

symptoms, 428 

treatment, 430 

bladder, perforation, 430 
laparotomy, exploratory, 430 
peritoneal cavity, perforation 

of, 43° 
septic peritonitis, 430 






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